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Level of EM Service?

  1. Default Level of EM Service?
    Medical Coding Books
    Help what level of EM would this be? Doc did not do a exam.
    Pt is here to discuss the MRI results of his right knee. Both the film and report were interpreted by Doc. These indicate an undersurface tear to the postermedial meniscus. He continues to complain of pain to his right knee with swelling and pain along the medial joint line.

    At this time it was recommended that he undergo an operative arthroscopy for a right knee medial meniscectomy. Risks and benefits of surgery were discussed and he does wish to proceed, It was recommended that he follow up with his primary care physician for medical clearance prior to undergoing surgery. He will call to schedule surgery for a time convenient for him.

    Thanks for the help

  2. #2
    Default
    99213.

    EPF history, you have a chief complaint, 1-3 HPI, 1 ROS.
    Low mdm, you have est problem not at goal or worsening and surgery.

    Laura, CPC

  3. #3
    Default 99213-57
    discuss the MRI results (CC)
    right knee, medial joint line (location)
    swelling (associated signs/sx)
    continuing pain (can argue severity, getting worse)

    .....
    ROS & PFSH are required for history for anything expanded problem focused and above .... so as is, your documentation for history is problem focused correlating to a level 2. However, if I pulled say, "swelling", I could use that for one ROS - which is required for an Expanded Problem Focused History. Since this is a "follow up" to MRI results, this type of documentation is typical because I'm *assuming* ROS and PFSH were obtained at last encounter ... if so, then your physician should reference that document including the date, and that no changes have been made, or if there are changes to indicate them ... then we wouldn't have to pull and stretch things
    .....

    Both the film and report were interpreted by Doc. These indicate an undersurface tear to the postermedial meniscus. (I'm assuming interpreted by radiology? if your physician said he independently reviewed I would give him 2 data points -- but I will give him 1 point for reviewing test)

    At this time it was recommended that he undergo an operative arthroscopy for a right knee medial meniscectomy. (moderate risk)

    for MDM,
    --established problem, worsening .... 2 points
    --order/review MRI .... 1 point
    --arthroscopy .... moderate risk

    overall MDM is LOW

    so ..... you have a 99213 and don't forget your modifier 57! for the decision for surgery

  4. Default
    Thanks so much for the help it is hard to code these. Grandma Cora

  5. #5
    Default
    Did your provider document the time he spent with this pt? This look to me as though the majority of this encounter was in counseling. If counseling dominates the visit then it would be appropriate to bill based on time. In order to do so the total time spent must be documented, as well as that over half was spent in counseling and some indication as to what was discussed - in your case the MRI results and risks/benefits of surgery.
    Karolina, CPC, CPMA, CEMC

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