Level of MDM / Factoring in Health Factors

KStaten

Networker
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This is yet another crazy question, but please bear with me. :)

If a provider is very brief in his / her documentation for the plan, can information be pulled by the coder from elsewhere in the note, even if the provider does not specifically link it to his/ her medical decision making for the problem at hand.

Example: A patient is being seen for a yearly follow-up of a joint replacement (outpatient) and the doctor ONLY documents the plan as such:
"The patient is doing well with her joint replacement. I will see the patient in a year." (No suggestions for OTC medicine, PT, nor intervention of any kind nor concerns of other health problems)

If, however, when searching the note, it is documented in the patient's problem list (collected previously) that the patient is a diabetic, has cardiac issues, etc can this be considered when choosing the level of MDM for the E/M level even if the provider does not document that the other health factors factor into the continued care for the problem currently being treated? For instance, I would consider this a 99212 based on the plan, but could the provider justify it being a 99213 simply because the patient has other health problems in their problem list, even though no documentation suggests concerns nor special treatment / precautions?

THANK YOU! I appreciate your input greatly!
 

thomas7331

True Blue
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No, a coder cannot make the assumption that conditions or factors that were present at previous encounters still exist. Because of this, it's not considered compliant coding to use information from past encounters to code for the current encounter, unless the provider, in the current note, specifically references that information and confirms that those conditions are still present and continue to affect or influence treatment.
 

KStaten

Networker
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Charleston, West Virginia
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No, a coder cannot make the assumption that conditions or factors that were present at previous encounters still exist. Because of this, it's not considered compliant coding to use information from past encounters to code for the current encounter, unless the provider, in the current note, specifically references that information and confirms that those conditions are still present and continue to affect or influence treatment.
Thank you! :) I have been trying to emphasize that we can ONLY code from what has been documented, and, as you have stated, we cannot assume anything that the doctor has not clearly stated/ suggested. I have been having debates as to whether I am coding these correctly as 99212, rather than a 99213, when the plans are brief and do not recommend any further treatment nor reasons for concern. It is clear to me that these are by no means a Level 3, but it is still being questioned. Thank you once again!
 

Mnmark442

Contributor
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I agree. We were recently going over this at my job. We had this as an example: patient was coming in for cardiac pre op clearance. Patient had a tons of issues, but he only documented “patient with MS is here for cardiac clearance….”

We debated if this was relevant and amongst 4 coders, agreed since he specifically stated MS (which he considered as part of his MDM for the clearance). The other diagnosis codes listed, were not mentioned and therefore we did not use when leveling the visit.

If it helps, with a lot of aspects of coding, especiallyyyy E/M has a lot of what we call “gray areas.” Some E/M’s are borderline between 99213 or a 99214 for example. Use your best judgement, do research and stick to the facts.
 
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