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99212 vs 99213-I posted this

  1. #1
    Default 99212 vs 99213-I posted this
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    Dear Coders,
    Yesterday I posted this question in the general section and received no response. I hope someone can assist me in this section. This is a rather lengthy questions, so please bear with me. A patient presents to the Ophthalmologist for a complete eye examination. The examination is performed and a diagnosis of cataracts in both eyes is documented along with the discussion for cataract surgery. The patient wants to think about the surgery and leaves the office. A week or sometimes a month later, the patient requests another visit with the Ophthalmologist and decides to go ahead with the surgery. What E & M code would be appropriate for this second visit?
    CC: F/U cataracts
    HPI: All bullets completely filled out
    Examination: The same as the complete eye exam except the patient has not been dilated again therefore, fundus, optic nerve, post. segment, vitreous have not been documented.
    A/P: patient has decided to book the surgery and the a-scan is scheduled. I am not sure if I can give credit for the surgical portion again. As it was given on the previous visit. I know that medical necessity drives a visit and not the amount of bullets completed. I would like to find something in writing one way or the other that will spell it out without question. Thank you in advance for your help.

  2. #2
    Can you please post what was actually documented? I'd be more than happy to give my opinion but I need more info.


    Laura, CPC, CEMC

  3. #3
    On the original visit 8/25/09 everything is completed. On the following visit 9/2/09
    CC: F/U cataracts
    HPI: ou, glare, moderate, year, anytime, driving,
    Exam: pupils, conf. VF, motility, adnexae, conjunctiva, cornea, a/c, lens
    all addressed as normal or abnormal
    A/P cataracts ou
    Then the a-scan is scheduled. Again I have given credit for the surgery discussion on the prior visit 8/25/09. Do you code this a 99212 or 99213
    Thank you,

  4. #4
    I would say 99212 based on what you have posted.

    Cataract at this point is an established stable problem, so you are stuck with straightforward MDM.

    The difference could be in your history, though. It looks to me like you have an expanded problem focus exam (based on 97 single system eye). So if you have enough history this could be a 99213 based on history and exam.

    Hope this helps,

    Laura, CPC, CEMC

  5. #5
    Dear Laura,
    The history portion is an initialed space that states it has been reviewed. No comment is made regarding each body system separately. Thank you again for your time.

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