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Level of service for PrEp and PEP visit

M

Mahmad0710

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2
Location
Overland Park, KS
Hi, I have a question about level of service for PrEp and PEP visit. the provider ordered 4 labs and prescribed medication. she also coded it as at risk of High sexual behavior. based on 2021 MDM table, this visit should be moderate level. is this correct???
 
Office visit E&M leveling is based on meeting 2 of 3 for problem, data and risk. As you stated, the data is moderate (4 tests) and risk is moderate (Rx issued). Since at least 2 of 3 are moderate, that is 99204 or 99214.
 
This is what I told the provider but she is afraid that this is a high level for a person who comes to the clinic and in her mind that this visit is just prevention. I told her as long as you prescribed medication, then the risk is moderate with the labs you ordered.
Thank you Christine.
 
We have providers fight us on this too, I agree it is level 4 but I often wonder where it fits in the complexity of problems addressed? Seems like it isn't acute or chronic but more counseling. How do I explain the first piece of the MDM grid to the providers? I know labs and rx meds count as moderate in the two other areas.
 
crystalkay said:
We have providers fight us on this too, I agree it is level 4 but I often wonder where it fits in the complexity of problems addressed? Seems like it isn't acute or chronic but more counseling. How do I explain the first piece of the MDM grid to the providers? I know labs and rx meds count as moderate in the two other areas.
Click to expand...
For me, if I already have 2 levels the same, I don't even bother leveling the third category.
This is not a problem my providers are treating/addressing, but I suppose I would put the problem as low in most circumstances. Perhaps being closest to an acute uncomplicated illness or injury? Depending on what diagnosis the provider is documenting, and the level of detail, MAYBE moderate. I suppose in extreme circumstances, it might even be high "acute/chronic injury that poses a threat to life" - like for a patient who is a sex worker or IV drug user not using clean supplies.
 
csperoni said:
For me, if I already have 2 levels the same, I don't even bother leveling the third category.
This is not a problem my providers are treating/addressing, but I suppose I would put the problem as low in most circumstances. Perhaps being closest to an acute uncomplicated illness or injury? Depending on what diagnosis the provider is documenting, and the level of detail, MAYBE moderate. I suppose in extreme circumstances, it might even be high "acute/chronic injury that poses a threat to life" - like for a patient who is a sex worker or IV drug user not using clean supplies.
Click to expand...
Agree, if it is really just a screening a think it is N/A or minimal in problems addressed but still fits level 4 for data and risk. That would also make sense for a higher level if IV drug user etc. Thanks for your feedback.
 
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