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Upper Respiratory Infection with comorbidities

  1. Default Upper Respiratory Infection with comorbidities
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    In regards to number of diagnoses or management options, how do we count: If pt has diabetes and Hypertension as comorbidities with URI? (And if Rx is given for cough or URI symptoms)
    how about COPD with URI would that still be a 99213? (assuming Rx is given)
    thank you

  2. #2
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    Remember that in order to count anything towards the Diagnosis and/or Management Options in the Medical Decision Making portion, the provider has to do active management of the problems spelled out in the documentation. If the provider is accepting and managing a patient's problem (say, URI), based on documentation you will have to discern whether the problem (I use the Marshfield Clinic tool):

    • Self Limited/Minor
    • Established Stable/improving
    • Established Worsening
    • New Problem to the examiner w/o additional workup
    • New Problem to the Examiner w/ additional workup


    Again, depending on documentation, the status of the problem and what is medically necessary you might be able to assign it to either of the above choices. If you don't want to use the Marshfield Clinic tool, then CMS suggests a range from Minimal to Extensive in terms of complexity. This is quite a bit more vague and is more qualitative rather than quantitative (Marshfield Clinic tool).

    Also, just because the provider is prescribing an Rx, doesn't automatically (although suggestive) mean a Moderate Risk under Management Risk Options. The Rx still have to be medically necessary in order to be used for credit.

    Finally, you didn't mention anything about the patient's History and Exam. You did suggest a 99213, hinting towards the visit being an Established Patient visit. For Established Patient visits, two of the three E/M components (History, Exam and MDM) must meet the E/M level picked otherwise the lowest E/M level should be billed. Some argue that any of the three E/M components can be counted towards the E/M level, while others suggest that the MDM component should be one of the two E/M components.

    Hope this is helpful!
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

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