Wiki MDM - 2021 Guidelines

[KoBee]

Would like some opinions and expertise if possible please. Not sure why I am questioning but I want to make sure I’m doing something correct.



If a patient comes in for:


Acute, uncomplicated injury = treats with ibuprofen 800mg (prescription med). Data/complexity (none)

Stable HTN/DM = treats with continue regimen and medication, no changes. Data/complexity (none)



Would this fall under 99213 because HTN/DM doesn't meet the 2 out the three elements. The only thing they are really treating with something is the uncomplicated injury, which doesn’t meet the 2 out of 3 elements.

 

[NathaliePaulson]

HI I primarily deal with GI but came across your post and wanted to tell you - my understanding is that yes, this would be a 99213 due to HTN being a stable, chronic illness. It is used as an example in the guidelines.

Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). “Stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, in a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic, the risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, noninsulin- dependent diabetes, cataract, or benign prostatic hyperplasia

 

[csperoni]

I would code this 99214
I agree if it was HTN only, 99213. However, this pt had HTN & DM, both being addressed. That's 2 chronic stable.
Number & complexity of problems: level 4 (for 2 stable chronic)
Data: level 2 (minimal/none)
Risk: level 4 (prescription drug management)
Even though the prescription is for the acute uncomplicated injury, it was still performed and still counts.