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kwatson0

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Good Afternoon we recently debated and needed some opinions, Pt comes in for follow up fasting labs with Hyperlipid.. 2 LABS 1 chronic or 1 minimal 2 labs . 99212 or 99213
Thank you!
 
It always depends on the documentation. Hyperlipidemia would TYPICALLY be a chronic condition. Assuming it is stable, (low problem) and the provider ordered 2 unique lab tests (low data), you would get 99213. The way your question is worded, "follow up fasting labs", if the labs were previously ordered, you would not count the review as it is included, or maybe the patient was just there for a blood draw which wouldn't be an E&M at all. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
 
csperoni said:
It always depends on the documentation. Hyperlipidemia would TYPICALLY be a chronic condition. Assuming it is stable, (low problem) and the provider ordered 2 unique lab tests (low data), you would get 99213. The way your question is worded, "follow up fasting labs", if the labs were previously ordered, you would not count the review as it is included, or maybe the patient was just there for a blood draw which wouldn't be an E&M at all. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
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Thank you, how do you feel about patient here for medication refills, Htn Hyperlipid (meds rx fu 3mths ) I considered this 99214, other coder 99213. Yes all rx were written appropriately. Other coder rationale, instead of 2 chronic stable because it's for a refill ie 2 self limited with moderate MDM coding it to level 3 (99213)
 
kwatson0 said:
Thank you, how do you feel about patient here for medication refills, Htn Hyperlipid (meds rx fu 3mths ) I considered this 99214, other coder 99213. Yes all rx were written appropriately. Other coder rationale, instead of 2 chronic stable because it's for a refill ie 2 self limited with moderate MDM coding it to level 3 (99213)
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If the provider is documenting the status of 2 problems as chronic and stable, then performs prescription drug management, that is a level 4 outpatient. In a case of poor documentation, 99213 may be more appropriate. Remember you can only code per the documentation, and not by the service actually provided if the documentation is lacking.
"Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status."
I would not consider documented HTN or hyperlipidemia requiring prescriptions to meet the definition of self limited/minor problem.
 
Hello everyone, I have a follow up question.

If a patient is seen at Cardiology office, patient being followed up for 4 month follow up for ONE chronic stable illness (say HTN) and pacemaker device check, provider is not making any medication changes, and the documentation states this,
  • Blood pressure in office today 140 systolic. Patient states that she has been monitoring her pressure at home and average systolic pressures ranging from around 126. Not advising any further medication changes today.
  • Patient on Eliquis for history of recurrent DVT, PE she denies any bleeding concerns and is tolerating it well.
  • Labs were reviewed GFR 87 no lipid panel or A1c available. Will order lipid panel for review today and request labs from PCP.
My questions are:
1. If my cardiologist is managing the prescription for HTN,
Can I count the history of recurrent DVT and checking on the status of the dyslipidemia/DM for the number of problems addressed here and say - 99214?
or consider this as ONE chronic stable illness (say HTN) - 99213

2. If PCP is managing the drug and my specialist documents the above - would that be 99213?
 
I don't see drug management in your statement, who ordered the GFR, was it another Provider.. If that is the case Provider should state ..( 2 labs, 2 chronic conditions 99213)
 
Established pediatric patient, f/u hematuria, proteinuria, mild, duration 1 month, urinalysis done in office, suggested f/u labs, no rx, no other tests. This appears very straight forward. Would this support a 99212 or 99213?
 
Aht2016 said:
Established pediatric patient, f/u hematuria, proteinuria, mild, duration 1 month, urinalysis done in office, suggested f/u labs, no rx, no other tests. This appears very straight forward. Would this support a 99212 or 99213?
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What would you level each of:
Problem
Data
Risk?
 
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