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99212 or 99213

  1. #1
    Question 99212 or 99213
    Medical Coding Books
    We have a patient who came in with an arm injury. The nurse did temp, bp and weight. HPI states played multiple sports this w/e, very sore yesterday and this am, better now but still sore over distal femur with flexion.
    Works construction using nail gun daily right hand.

    PE: Gen appearance wdwn, nad
    Extremity: r elbow sl swollen over dorsum of r humerus/triceps tendon with ttp, FROM with some stiffness on full flexion, equal hand grasps.
    Neuro: neuro circ intact distally

    Assessment: tendonitis R tricep

    Plan: rest, ice, ibuprofen

    To me this looks like a 99212 since mdm is straightforward. Doctor wants me to bill 99213. What do you think???? thanks

  2. #2
    Stuart, Florida
    I agree with you. To me, this looks to be 99212. My doctors often check off an E/M code on our encounters. I ignore it and make my own decisions when it comes down to it.
    Vanessa Mier, CPC

  3. #3
    Default 99212/99213
    Thanks Vanessa. That's what I thought. I'm going to go back to him and show him why it's a 99212 and not a 99213 for his future reference.

  4. #4
    South Bend
    Something else to consider?

    The nature of the presenting problem (page 7 of CPT)

    All depends on where you place it (self-limited or minor/low severity).

    Just my two cents.


  5. Default 99213
    These are my thoughts. I agree with the provider.

    HPI - 4 elements (timing, duration, context, location)

    Ros-1 (Musculoskeletal)-sore over distal femur with flexion

    Exam-Problem-focused (5 elements)

    MDM-Low -over-the-counter meds (Ibuprofen)

    E Evans, CPC

  6. Smile P. Scully, CPC
    I completely agree with E. Evans - a perfect E&M analysis for 99213 remibursement.

  7. #7
    Default 99212/99213
    Just because the doctor told him to take an ibuprofen that makes it a low complexity mdm? There are no chronic illnesses listed, not 2 or more limited/minor problems or even an acute injury. I think this is a self limited minor problem but he did tell the patient to use ibuprofen for the pain so that makes it ok to bill 99213?? just wanted to clarify! thanks for everyones input

  8. #8
    Stuart, Florida
    There are e/m audit worksheets that you can get that will help you with this. I wish I had saved the link on my work computer when I had internet access. Our company blocks just about everything on our computers so I can't even google it but I'm sure you can find it. I went ahead and plugged the info given, from your note, into the worksheet that I have and I still get a 99212....
    Vanessa Mier, CPC

  9. #9
    Overland Park, KS
    I get a 99213. I get an EPF history (4 elements of HPI, 1 ROS, 1 PFSH), and PF exam and the MDM is low complexity. If you want to look at the points: 3 points for a new problem to provider, 0 points for data, and the risk is low because of the nature of the presenting problem. It is an acute, uncomplicated injury. You would also get low risk for the OTC meds.

    Just my two cents!
    Last edited by dballard2004; 07-22-2010 at 01:55 PM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  10. #10
    I too get a 99213. You only need 2 of the three components so you don't even need the MDM, you can get it from your HPI and exam.

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