Wiki Risk - how to use "with identified patient or procedure risk factors" for E/M with procedure

[flowergrl]

Scenario for determining E/M with injection CPT 20610 - Patient presents for a knee pain problem and a decision is made to do a minor office procedure such as a knee cortisone injection on the same day as the visit. Does the overall personal health status of the patient matter for the E/M "Risk" leveling? Lets assume the provider puts in enough documentation to support using an E/M with the 20610 for the purposes of this discussion.

Scenario A - patient is a uncontrolled diabetic, 85 yo, uses a walker and already had a knee replacement of the opposite knee, and has CHF and COPD. Would you consider the E/M risk Moderate level "Decision regarding minor surgery with identified patient or procedure risk factors" - This patient has personal, identifiable risk to getting an injection that a healthier person may not have. Provider documents discussion of injection risk.
1. Moderate = Problems Addressed as "1+ Chronic illness with exacerbation/progression" (has had this knee pain for many years, recently worse, OA progressing, no previous shots)
2. Minimal = No data reviewed (reviewed knee xray from other facility but only read the report, no independent review of images)
3. Moderate = "Decision regarding minor surgery with identified patient or procedure risk factors" (patient has multiple health problems already, in addition to the risk of injection)
99204/99214


Scenario B - patient is a healthy 50 yo, no previous treatment of knee (no surgeries, shots) and no other general health comorbidities. Patient has no personal, specifically identifiable extra health risk to getting a knee injection today other than the risk of the injection itself. Provider documents discussion of injection risk.
1. Moderate = Problems Addressed as "1+ chronic illness with exacerbation/progression" (has had knee pain for over a year, recently worse after exercise)
2. Minimal = No data reviewed (did 1 xray in office, billed separately)
3. Low = Patient does not have identified personal risk factors *other than the injection today*.
99203/99213

Does the joint injection risk itself qualify as Moderate level when risks of the injection are documented, regardless of the health of the patient?
My point is...as long as the provider identifies injection risk factors by adding "Risks and benefits of injection were discussed such as infection, etc..." - which should always be documented when discussing a joint injection, does that alone make it Moderate Risk?
Or should that Moderate risk level really read "Decision regarding minor surgery with additional, personal identified patient or procedure risk factors" ?
Thoughts?

 

[jkyles]

Scenario for determining E/M with injection CPT 20610 - Patient presents for a knee pain problem and a decision is made to do a minor office procedure such as a knee cortisone injection on the same day as the visit. Does the overall personal health status of the patient matter for the E/M "Risk" leveling? Lets assume the provider puts in enough documentation to support using an E/M with the 20610 for the purposes of this discussion.

Scenario A - patient is a uncontrolled diabetic, 85 yo, uses a walker and already had a knee replacement of the opposite knee, and has CHF and COPD. Would you consider the E/M risk Moderate level "Decision regarding minor surgery with identified patient or procedure risk factors" - This patient has personal, identifiable risk to getting an injection that a healthier person may not have. Provider documents discussion of injection risk.
1. Moderate = Problems Addressed as "1+ Chronic illness with exacerbation/progression" (has had this knee pain for many years, recently worse, OA progressing, no previous shots)
2. Minimal = No data reviewed (reviewed knee xray from other facility but only read the report, no independent review of images)
3. Moderate = "Decision regarding minor surgery with identified patient or procedure risk factors" (patient has multiple health problems already, in addition to the risk of injection)
99204/99214


Scenario B - patient is a healthy 50 yo, no previous treatment of knee (no surgeries, shots) and no other general health comorbidities. Patient has no personal, specifically identifiable extra health risk to getting a knee injection today other than the risk of the injection itself. Provider documents discussion of injection risk.
1. Moderate = Problems Addressed as "1+ chronic illness with exacerbation/progression" (has had knee pain for over a year, recently worse after exercise)
2. Minimal = No data reviewed (did 1 xray in office, billed separately)
3. Low = Patient does not have identified personal risk factors *other than the injection today*.
99203/99213

Does the joint injection risk itself qualify as Moderate level when risks of the injection are documented, regardless of the health of the patient?
My point is...as long as the provider identifies injection risk factors by adding "Risks and benefits of injection were discussed such as infection, etc..." - which should always be documented when discussing a joint injection, does that alone make it Moderate Risk?
Or should that Moderate risk level really read "Decision regarding minor surgery with additional, personal identified patient or procedure risk factors" ?
Thoughts?

Hi there,
All levels of risk are specific to the patient and procedure considered during the encounter. You don't use the usual risks of a procedure - eg the risks outlined in the consent form - to calculate MDM. Otherwise everything would be high risk The AMA addressed this in an FAQ here https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management-em-revisions-faqs

Q. Question: Do inherent risks (e.g., perforation) make all surgeries high risk to patients when selecting the level of risk for medical decision-making?​

A. CPT coding does not define ordinary surgical risks (such as perforation) as high or low risk for patients. The physician or QHP who evaluates the patient is the best judge of the specific patient factors that make a procedure "high risk" for a patient.

Another general rule - the provider should clearly state the level of risk (see the definition of risk in the CPT manual).
For scenario A in particular the treating provider would need to clearly document the connection between the patient's various conditions and the risks of the injection. Also, how they planned to manage those risks. That's all part of their MDM.