Question New E&M coding question

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I am having push back from a provider that believes I am coding "too high" and that with the new guidelines, what was a 99214 is often now a 99213. example, patient presents with vaginal discharge. pertinent social & medical history done, weight, bp and pelvic exam done. provider does a wet mount and reviews the slide. diagnoses BV (N76.0) and gives rx for metrogel. Depending on social history, may order chlamydia and GC testing, sample collected and sent out.

I believe this is still a 99214 but provider thinks in both cases (with or without the std screening) it is a 99213. what is your vote?
 
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I completely understand your argument as well as the push back from your physician. I have been coding OB/GYN for 10+ years. Prior to the new E/M updates, this would have been a textbook 99213. However, using the new MDM making table, I see your 99214. Number and Complexity of Problems Address: Low; Amount and/or Complexity of Data to be Reviewed and Analyzed: Moderate ; Risk of Complications: Moderate (due to Rx) : 2 out of 3 = Moderate 99214

Just an idea: I created a single page quick reference guide with the new MDM table and Time table for each of our providers to use. This has been very helpful for them to ensure they are documenting appropriately as well as helping them remember and/or interpret the new guidelines.
 

csperoni

True Blue
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I get moderate data only if the additional labs (chlamydia and GC testing) noted as MAY order. Otherwise, 99213.
Number & Complexity: Level 3. LOW for acute, uncomplicated illness
Data: Level 2, 3 or 4. MINIMAL level 2 if 1 test; LIMITED level 3 if 2 tests; MODERATE level 4 if 3 or more tests. (assuming no independent historian or independent interpretation)
Risk: Level 4. MODERATE for rx issued

Definitely one of the significant changes is that you receive data points for EACH lab issued, where previously it was all labs on the date. To me, that is the difference here.
 
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