Wiki Tubal Consult Level?

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cnramsey

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What level would you go with for the Number and Complexity of problems addressed for a Tubal consult?

I can't use the consult codes due to the patients insurance.

Patient is new to the surgeon and seen in the office. I'm working the Risk up as a 99204 he talked to the patient about the type of surgeries and risks. He mentions he read the referring providers note. But I'm struggling with what level to pick for the problem addressed since it's hard to see a decision for tubal ligation as as a chronic illness, new problem uncertain prognosis, acute illness with systemic symptoms or acute complicated injury.

Provider has picked a 99204 and he did not state time spent.

Any help with this type of visit will be greatly appreciated.

Nichole
 
For a patient having surgery, 99% of the time, I can get at least level 4 from data and risk. I'm certain before surgery that provider is ordering some blood work - pregnancy test, blood type, CBC, SMA7, etc. You already have 1 for review of prior external note. As long as he ordered 2 tests, you meet level 4 for data category 1. Decision regarding minor surgery with identified patient or procedure risk factors is also level 4.

Since you need to meet 2 of 3 MDM elements, you don't even need to calculate the number and complexity of problems. If you did, I guess I would consider it a stable chronic problem. It will last > 1 year (pt will continue to be able to get pregnant without the surgical intervention).

So if provider ordered at least 2 tests (or otherwise met data level 4) I would code level 4. If not, level 3.

From the AMA 2021 guide:
Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient.
They further define Problem: A problem is a disease, condition, illness,injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
 
csperoni said:
For a patient having surgery, 99% of the time, I can get at least level 4 from data and risk. I'm certain before surgery that provider is ordering some blood work - pregnancy test, blood type, CBC, SMA7, etc. You already have 1 for review of prior external note. As long as he ordered 2 tests, you meet level 4 for data category 1. Decision regarding minor surgery with identified patient or procedure risk factors is also level 4.

Since you need to meet 2 of 3 MDM elements, you don't even need to calculate the number and complexity of problems. If you did, I guess I would consider it a stable chronic problem. It will last > 1 year (pt will continue to be able to get pregnant without the surgical intervention).

So if provider ordered at least 2 tests (or otherwise met data level 4) I would code level 4. If not, level 3.

From the AMA 2021 guide:
Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient.
They further define Problem: A problem is a disease, condition, illness,injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
Click to expand...
They ordered no other test that I can see. I even had our other coder look and nothing. Thank you for the insight about 1 chronic stable though!
 
Can I point out that you would not be using the consultation codes regardless of the patient's insurance? Just because one doctor sent a patient to your doctor to have surgery does not make it a consultation.
 
cnramsey said:
They ordered no other test that I can see. I even had our other coder look and nothing. Thank you for the insight about 1 chronic stable though!
Click to expand...
We also sent a question to ACOG and this is what they came back with.
Addressing the issue of contraception is unquestionably a “minimal” or “self-limited” problem. If birth control methods are used to address other medical problems, such as menorrhagia or dysmenorrhea, it could rise to a “low” problem because of the issues, not the use of contraception to treat it.

Tubal ligation or bilateral salpingectomy cannot be considered a chronic problem because it is an elective choice and it disappears if/when the patient has the procedure. While a discussion about this procedure would have a moderate level of risk, it is difficult to comprehend how it would be more than a minimal level of problems. If data is considered and documented, that may elevate the service to a low or moderate level of medical decision making.

Depending on the circumstance, time based billing may produce the best outcome for the physician, provided that the time is appropriately documented.
 
cnramsey said:
We also sent a question to ACOG and this is what they came back with.
Addressing the issue of contraception is unquestionably a “minimal” or “self-limited” problem. If birth control methods are used to address other medical problems, such as menorrhagia or dysmenorrhea, it could rise to a “low” problem because of the issues, not the use of contraception to treat it.

Tubal ligation or bilateral salpingectomy cannot be considered a chronic problem because it is an elective choice and it disappears if/when the patient has the procedure. While a discussion about this procedure would have a moderate level of risk, it is difficult to comprehend how it would be more than a minimal level of problems. If data is considered and documented, that may elevate the service to a low or moderate level of medical decision making.

Depending on the circumstance, time based billing may produce the best outcome for the physician, provided that the time is appropriately documented.
Click to expand...
Good to hear the input from ACOG. My rationale was that this is a condition (which is included in the problem definition by AMA) which will last > 1 year. But I would certainly defer to the expert advice of ACOG.
As I mentioned in my original post, I still believe the provider would be ordering some type of PST or medical clearance labwork. I can't imagine any facility that would do a tubal ligation without first having a pregnancy test. Most providers/anesthesiologists/facilities will also want additional testing, based on the age/history of the patient. I would suggest asking your providers if they are ordering any labwork, or even standing orders for certain labwork. It is very possible they are entering this in some other system (like the hospital EMR) and it's not properly documented in the outpatient E/M note. I personally had this issue and we needed to develop a way to add this documentation so we could properly credit the providers for tests ordered when leveling E/M.
 
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