Wiki Practicode Cases E/M

[lburgos31]

Hello eveyone, hopefully someone can help me with this.

I've been mostly experienced with Orthopedic Coding for the past 3 years and im trying to branch out. I wanted to find some training that wasnt expensive, so i purchased an E/M module from AAPC for 50 bucks. It has 20 cases to code, I believe.

I need someone to help me understand this case and rationale. I coded a 99213 and J18.8. The rationale coded 99212 and J18.9.

I thought because tests were ordered along with medication management this would constitute a 99213. Also, j18.9 is unspecified. I thought we should never code unspecified when a code for other is available?

Please let me know what you think. Thanks


Internal Medicine
Dr.Jack Kramer


Rebecca Smith
DOB: 01/xx/1927
Private Payer (Medicare rules for 65 and older)

DOS: 01/01/20XX
Office Visit, Est

Subjective: Patient was recently seen at the ER and diagnosed w/ right-sided pneumonia. She was placed on a Z-pak which she has finished. She does continue to cough. It is nonproductive. She denies any acute shortness of breath or temperature. She denies any known wheezing. She does feel like she is getting better. She denies any fever, chills, or sweats. She does have an active cough, but denies any shortness of breath or wheezing. She denies any chest pain, palpitations, syncope, or edema.

Objective: Physical Exam: W: 125lbs; H: 5'4"; T: 97.5; BP: 90/60; Pulse: 57; Respirations: 16; Pulse Ox: 96% on rm air. She is alert and responsive. She has a cough, but she is in no respiratory distress. HEART: RRR, w/o murmurs, clicks, or rubs. LUNGS: Reveal some coarse rhonchi, but no rales wheezing. She has good breath sounds. Posterior oropharynx has no redness or swelling. No tonsillar hypertrophy or exudate. No evidence of any rash.


Assessment: Resolving Pneumonia

Plan: We recommend she get a repeat chest x-ray next monday and we placed her on Tessalon Perles 200mg 1 three times a day. If she starts to run a fever again or become short of breath we want her to either present here or go to the ER. We will follow for the results of the chest x-ray.

Electronically signed by Jack Kramer, MD 1/1/20xx

 

[sls314]

You only use the Other diagnosis codes when the provider gives a detailed diagnosis, and there isn't a specific code for it. For example, Pleuropneumonia would be assigned J18.8. (NEC = Not Elsewhere Classified. A specific type of pneumonia that can't be classified under another diagnosis code.)

Unspecified codes are used when the provider doesn't detail a specific diagnosis. Pneumonia NOS would be assigned J18.9.

NOS = Not Otherwise Specified. The provider didn't state anything more specific than the word Pneumonia in this case, so J18.9 is correct.

 

[csperoni]

Regarding the code level - you need to meet or exceed 2 of 3 elements of MDM (number/complexity of problems; data; risk). I would also have coded 99213, not for data, but problems.
Risk - level 4 for prescription drug management
Data - level 2 for minimal or none. To meet level 3, you need to have TWO of: review prior external note; review each unique test; order each unique test or independent historian. Since only 1 test (CXR) was ordered, you do not meet level 3. In reality, the physician may have reviewed the ER records, or ER tests, but since it's not noted in the documentation, you can't count it.
Problems - I personally would call this level 3 for acute, uncomplicated illness, but could understand calling it level 2 since the problem is improving.
I suppose Practicode is considering the problem level 2. During an audit or review, I would confidently defend my 99213. Might not win, but would defend.

Per AMA https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
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.
Acute, uncomplicated illness or injury: 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. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

 

[AmandaBriggs]

My first question would be are they using 2021 guidelines or the 95/97 guidelines to level this E/M service?

 

[csperoni]

My first question would be are they using 2021 guidelines or the 95/97 guidelines to level this E/M service?

I didn't even think of 95/97. That already feels like forever ago since we have been preparing so long.
My reply was specifically for 2021 outpatient (MDM only).

 

[lburgos31]

My first question would be are they using 2021 guidelines or the 95/97 guidelines to level this E/M service?

That is a great question. I am going to have to reach out to AAPC support to find this out. I do not want to code these cases without the proper knowledge.

 

[lburgos31]

You only use the Other diagnosis codes when the provider gives a detailed diagnosis, and there isn't a specific code for it. For example, Pleuropneumonia would be assigned J18.8. (NEC = Not Elsewhere Classified. A specific type of pneumonia that can't be classified under another diagnosis code.)

Unspecified codes are used when the provider doesn't detail a specific diagnosis. Pneumonia NOS would be assigned J18.9.

NOS = Not Otherwise Specified. The provider didn't state anything more specific than the word Pneumonia in this case, so J18.9 is correct.

You've definitely cleared this up for me. Thank you!

 

[lburgos31]

Regarding the code level - you need to meet or exceed 2 of 3 elements of MDM (number/complexity of problems; data; risk). I would also have coded 99213, not for data, but problems.
Risk - level 4 for prescription drug management
Data - level 2 for minimal or none. To meet level 3, you need to have TWO of: review prior external note; review each unique test; order each unique test or independent historian. Since only 1 test (CXR) was ordered, you do not meet level 3. In reality, the physician may have reviewed the ER records, or ER tests, but since it's not noted in the documentation, you can't count it.
Problems - I personally would call this level 3 for acute, uncomplicated illness, but could understand calling it level 2 since the problem is improving.
I suppose Practicode is considering the problem level 2. During an audit or review, I would confidently defend my 99213. Might not win, but would defend.

Per AMA https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
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.
Acute, uncomplicated illness or injury: 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. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

Thanks for the information MDM, for some reason, always trips me up. I am going to review the file you posted here and hopefully helps stick it in my head Lol. Thanks!