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MDM Work-up or Not for Exploratory Lap

  1. #1
    Default MDM Work-up or Not for Exploratory Lap
    Medical Coding Books
    Would this scenario be considered "New Problem with work-up" or without?
    The provider admitted the patient from the ER and wants to charge a 99223.
    His assessment is acute perforated diverticulitis (confirmed by CT scan). His plan is emergent exploratory laparotomy with possible bowel resection & possible colostomy. 99223 requires High MDM so this is what we've got:
    Amt of Data: He reviewed labs and personally reviewed the CT scan (3 pts)
    Table of Risk: Emergency major surgery (4pts)
    # of Diags/Mgmt Options: Some coders consider the Exploratory Lap as work-up planned, others don't since the diag was known before the surgery and consider the exploratory lap as part of the treatment. (3 or 4 pts?)
    I'd be grateful for any opinions! Thanks-Sue
    Sue Vermette, CPC, CPMA

  2. #2
    Milwaukee WI
    Default Did he also ORDER the CT scan?
    If he also ORDERED the CT scan then you can give an additional point for that and you have 4 data points.

    As to the problem points, I'd tend to agree with those who said that the exploratory lap isn't really additional work-up because you already have a definitive diagnosis and seem pretty sure that the bowel resection will be needed. Does he give any indication of what "else" he might be looking for by doing the exploratory lap? If so, then I might give credit for the "new problem w/ work-up."

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Thanks for your thoughts! The CT was ordered by the ER doc. It sounds like the exploratory lap was to decide the best way to treat the problem, not looking for something else since he didn't mention any other concerns. I'll double check with the doc just in case he was thinking something that didn't get down on paper.
    Sue Vermette, CPC, CPMA

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