KStaten
Guru
Hello, Everyone. 
Dental prophylaxis is often recommended for patients following joint replacement, whereas any vulnerable areas for infection in the body can pose a potential risk. If, however, the doctor documents-- in a routine, yearly exam-- that there are no problems with the replacement and that he/she plans to see the patient, as scheduled in x number of years, but adds the recommendation for dental prophylaxis... would that increase the level of risk in the MDM?
Example: (Plan with no date being reviewed)
"The patient is recovering well following total knee arthroplasty. Weight bearing activities may be advanced as tolerated. At this time, I see no problems with the prosthesis. We will plan follow-up in1 year. I recommend dental prophylaxis. The patient will contact the office if they develop any change about the knee including wound drainage, increasing redness, pain or swelling."
I would otherwise consider this a 99212, but could it be argued that with the addition of the recommendation for dental prophylaxis, that it would become a 99213?
As always, thank you.
Dental prophylaxis is often recommended for patients following joint replacement, whereas any vulnerable areas for infection in the body can pose a potential risk. If, however, the doctor documents-- in a routine, yearly exam-- that there are no problems with the replacement and that he/she plans to see the patient, as scheduled in x number of years, but adds the recommendation for dental prophylaxis... would that increase the level of risk in the MDM?
Example: (Plan with no date being reviewed)
"The patient is recovering well following total knee arthroplasty. Weight bearing activities may be advanced as tolerated. At this time, I see no problems with the prosthesis. We will plan follow-up in1 year. I recommend dental prophylaxis. The patient will contact the office if they develop any change about the knee including wound drainage, increasing redness, pain or swelling."
I would otherwise consider this a 99212, but could it be argued that with the addition of the recommendation for dental prophylaxis, that it would become a 99213?
As always, thank you.