Korbc
Expert
this was addressed during an annual
"She is getting her periods once monthly and reports that the heavy flow has become more of a bother. She is changing her protection sometimes every hour. She also reports menstrual cramps that are bothersome. Her menstrual periods are not heavy every single month. We discussed that this is a pretty common scenario. She is counseled on treatment options for menorrhagia. She prefers to avoid anything hormonal, even IUD. We talked about endometrial ablation. For now, she would like to try Lysteda."
would you consider this 99213 with the annual or 99214. i have seen guidance for abnormal bleeding fall under moderate complexity of problems and it is rx mgmt. CPT does not distinguish rx mgmt as having to count if your are monitoring for side effects. Any kind of rx management suffices as moderate complexity from the books definition and multiple sources I've seen. but since extensive work up was not done but discussion of ablation did take place as well I'm not sure how to quite categorize this menorrhagia. And from what I've seen the doctor does have to mention specific dosage of the lysteda in the note for it to count towards rx mgmt?
any insights? thanks!
"She is getting her periods once monthly and reports that the heavy flow has become more of a bother. She is changing her protection sometimes every hour. She also reports menstrual cramps that are bothersome. Her menstrual periods are not heavy every single month. We discussed that this is a pretty common scenario. She is counseled on treatment options for menorrhagia. She prefers to avoid anything hormonal, even IUD. We talked about endometrial ablation. For now, she would like to try Lysteda."
would you consider this 99213 with the annual or 99214. i have seen guidance for abnormal bleeding fall under moderate complexity of problems and it is rx mgmt. CPT does not distinguish rx mgmt as having to count if your are monitoring for side effects. Any kind of rx management suffices as moderate complexity from the books definition and multiple sources I've seen. but since extensive work up was not done but discussion of ablation did take place as well I'm not sure how to quite categorize this menorrhagia. And from what I've seen the doctor does have to mention specific dosage of the lysteda in the note for it to count towards rx mgmt?
any insights? thanks!