mlandrus
New
The following example was used in training our providers on the new 2021 E/M guidelines. The final code was a 99212. Using the new 2021 MDM table and AMA definitions, credit was given for:
Number and complexity of problems addressed: Based on the definition of a limited or minimal problem (A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status), the URI falls under minimal.
Amount and/or complexity of data reviewed and analyzed: History obtained by mother meets for moderate data.
Risk of complications and/or morbidity or mortality of patient management: There was minimal risk to the patient from the treatment of the condition
However I have a pediatric group indicating that there is no way a 4 mo old with these symptoms would ever be a level 2. But according to the AMA definitions, limited or minor condition is a “problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.” And an acute uncomplicated problem is a ” recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.” I think this falls under minimal, but maybe I am wrong?
Also, from the August AAP newsletter, they have listed “cold” under a 99212 as a self-limited/minor problem.
Any help would be appreciated.
Chief Complaint: Congestion
HPI: Mom provided history. 4 mo old, started 2 days ago - congestion, yellow nasal drainage, not sleeping well, screaming in pain, cough. No fever.
ROS:
Constitutional: Not sleeping well. Denies fever/chills.
Eyes: Denies red eyes or eye drainage.
ENT: Runny nose and nasal congestion, postnasal drip. Denies sore throat, ear pain.
Respiratory: Daytime cough. Nighttime cough disturbs sleep.
Gastrointestinal: Denies vomiting, decreased appetite.
Physical Exam:
Constitutional: Normal general appearance: alert, pleasant, not ill appearing, no distress, smiling.
HEENT: Nasal mucosa, septum, and turbinates have mild mucoid d/c. Normal lips, teeth and gums, tonsils, posterior pharynx, hard & soft palate, oral mucosa, tympanic membranes and external canals.
Respiratory: Normal respiratory effort: symmetry and expansion of chest; auscultation of lungs.
Cardiovascular: Normal auscultation.
Assessment:
URI (J06.9)
Plan:
Suction nose AM and PM; elevate HOB; humidifier in room. Call if fever or labored breathing.
Thank you!
Number and complexity of problems addressed: Based on the definition of a limited or minimal problem (A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status), the URI falls under minimal.
Amount and/or complexity of data reviewed and analyzed: History obtained by mother meets for moderate data.
Risk of complications and/or morbidity or mortality of patient management: There was minimal risk to the patient from the treatment of the condition
However I have a pediatric group indicating that there is no way a 4 mo old with these symptoms would ever be a level 2. But according to the AMA definitions, limited or minor condition is a “problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.” And an acute uncomplicated problem is a ” recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.” I think this falls under minimal, but maybe I am wrong?
Also, from the August AAP newsletter, they have listed “cold” under a 99212 as a self-limited/minor problem.
Any help would be appreciated.
Chief Complaint: Congestion
HPI: Mom provided history. 4 mo old, started 2 days ago - congestion, yellow nasal drainage, not sleeping well, screaming in pain, cough. No fever.
ROS:
Constitutional: Not sleeping well. Denies fever/chills.
Eyes: Denies red eyes or eye drainage.
ENT: Runny nose and nasal congestion, postnasal drip. Denies sore throat, ear pain.
Respiratory: Daytime cough. Nighttime cough disturbs sleep.
Gastrointestinal: Denies vomiting, decreased appetite.
Physical Exam:
Constitutional: Normal general appearance: alert, pleasant, not ill appearing, no distress, smiling.
HEENT: Nasal mucosa, septum, and turbinates have mild mucoid d/c. Normal lips, teeth and gums, tonsils, posterior pharynx, hard & soft palate, oral mucosa, tympanic membranes and external canals.
Respiratory: Normal respiratory effort: symmetry and expansion of chest; auscultation of lungs.
Cardiovascular: Normal auscultation.
Assessment:
URI (J06.9)
Plan:
Suction nose AM and PM; elevate HOB; humidifier in room. Call if fever or labored breathing.
Thank you!
