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upcoding an E&M for writing an RX

com107

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One of the Doctor's I work for thinks you can up an E&M code because she wrote an RX. She did an 99212 but wants to have it coded a 99213 because she wrote an RX. This doesn't seem right to me. Has anyone ever heard that this is acceptable?
 
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jonvieve

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If the documentation can support an "expanded problem focused" history or exam, and there is documentation of the higher level of medical decision making then yes, the doctor should bill a 99213. Writing an Rx could certainly bump up the MDM to support a 99213, but it must be documented.

Say a patient comes to the office with a cheif complaint of a cough and has COPD, this chronic illness paired with the respiratory symptom would justify a higher MDM than a patient without a chronic condion and the same symptoms. The patient with COPD may require an Rx, while the doctor may just reccomend that the patient without a respiratory condition try an OTC medication.

So, yes, the need to write an Rx can bump a 99212 to a 99213 in a snap, but just writing the Rx does not justify the higher code.
 

btadlock1

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I agree...

If the documentation can support an "expanded problem focused" history or exam, and there is documentation of the higher level of medical decision making then yes, the doctor should bill a 99213. Writing an Rx could certainly bump up the MDM to support a 99213, but it must be documented.

Say a patient comes to the office with a cheif complaint of a cough and has COPD, this chronic illness paired with the respiratory symptom would justify a higher MDM than a patient without a chronic condion and the same symptoms. The patient with COPD may require an Rx, while the doctor may just reccomend that the patient without a respiratory condition try an OTC medication.

So, yes, the need to write an Rx can bump a 99212 to a 99213 in a snap, but just writing the Rx does not justify the higher code.
It depends on what the visit is for: jonvieve's example is of manangement of chronic illnesses, which could be considered potentially life-threatening (eventually) - 99213 could be appropriate in a case like that. But, if their presenting problem is minor or self-limited, then you're probably better off with the medically necessary code, 99212. Look at the examples in Appendix C (CPT) and see how your doctor's presenting problems stack up - you may not find precise examples, but they're close enough for comparison, most of the time.

Also, it's important that no matter how serious the problem, the provider must have at least 2 components that meet or exceed 99213's requirements (EPF Hx & Exam, Low MDM); otherwise it can't be billed. So you need at least this much (in 2 categories):
History: 1-3 HPI elements (or the status of 1-2 Chronic conditions), 1 ROS
Exam: 2-7 body areas and/or organ systems reviewed (95), or 6-11 bullets documented (97)
MDM: My MAC is Tralblazer, and they have their own system for scoring MDM, so I have to reference it - sorry if it's not helpful - check with your MAC to be sure, but when I score an encounter, writing a prescription counts as 1 possible diagnosis/treatment options point (Which equals straightforward MDM on its own), plus moderate risk (according to the table of risk), which averages out to Straightforward MDM - there has to be at least one other treatment option point, or 2 points from the data table, to equal a Low MDM. You only need 2/3 in MDM to select the overall level.

Hope that helps!;)
 
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