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office visits for color checks

  1. #1
    Default office visits for color checks
    Medical Coding Books
    Are most color checks coded as a 99213? or a 99212? I have various differences in my pediatric physicians. There is no medical prescribed and on one hand Jaundice sounds serious to me but the physician will state he told the mother this is normal.

    What do you normally see?

    Thanks,

    Raechel

  2. #2
    Default
    It all depends on the notes. Remember that it takes at least 2 out of 3 to bill an established E/M - to determine the MDM, assess the patient's prognosis (both with or without treatment), the # or severity of any co-morbidities, and how much data (from labs/etc) will have to be ordered/reviewed for diagnostic purposes:

    99212:
    Problem focused history
    Problem focused Exam
    MDM of low complexity

    99213:
    Expanded PF History
    Expanded PF exam
    MDM of low/moderate complexity

    (If I mis-stated any of that, PLEASE correct me - I don't have my books handy so this is off the top of my head)

    Go to this page:
    https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp
    And review the Downloads links. They will explain it all in painstaking detail.

    PS - if it were me, I probably wouldn't bill an office visit for a color check, unless there was quite a bit more to the visit than that. If I did, it would probably be a 99211 at best. It's similar to a weight check for newborns, and it may actually fall within a global period from the baby's birth, but I could be totally making that up in my head. Without my coding books, all I can do is guess on that kind of stuff - I haven't memorized them, yet. I'd check the American Academy of Pediatrics for typical practice standards on the issue.
    Last edited by btadlock1; 12-12-2010 at 12:05 PM.

  3. #3
    Default
    I appreciate the reply and completely understand about the documentation. I think the key question is medical decision making. With the EMRs today the 99213's would be abundant if I only used the exam and the HPI but I feel the MDM must be a key component. I was leaning towards a 99212 during an audit when I was told a color check is always a 99213. Of course really the doctor should determine the MDM. I'm rambling

    Raechel

  4. #4
    Default
    Quote Originally Posted by raechelz View Post
    I appreciate the reply and completely understand about the documentation. I think the key question is medical decision making. With the EMRs today the 99213's would be abundant if I only used the exam and the HPI but I feel the MDM must be a key component. I was leaning towards a 99212 during an audit when I was told a color check is always a 99213. Of course really the doctor should determine the MDM. I'm rambling

    Raechel
    "Always" is a strong word when you're dealing with things on a case by case basis. An unremarkable color check wouldn't require much (if any) MDM. Abnormal outcomes should be judged by the severity of the condition, and the resulting course of actions that are taken. If the prognosis is good, and there are no risks with the diagnostic and/or treatment processes, the MDM is minimal to low. Both of those CMS guideline links have a "Table of Risk" towards the end, which really helps to categorize the MDM from each encounter, the way that an auditor would. There's also a tool to assess the amount and complexity of data to be reviewed, and one to assess the number of possible diagnosis/management options, which both contribute to the overall MDM. I can't remember if there are instructions, or just the tables, so just in case...

    On the table of risk, the highest level applicable to the visit in any of the 3 columns is the overall level of risk.

    The other 2 charts are kind of self-explanatory. The # of Dx/Tx options and amount/complexity of data will correspond with ratings from minimal to high. You take the ratings from those categories and the overall risk, and the highest level achieved in 2 out of the 3 categories equals the MDM for most situations.

    So, for example:
    If there is no data being reviewed, that category = minimal
    If the # of Diagnosis/Treatment options category = low, and
    If the overall risk from the table of risk = Moderate

    Then the MDM will likely be low for the encounter. It's not a perfect system, though, because some of the variables can produce artificially high results, so you still have to use your judgement.

    I know I did a horrible job of explaining all of that just now, so if you decide to use that method to determine MDM and have any questions about it, let me know and I'll go more into depth...

    (And you thought YOU were rambling...ha!)

  5. #5
    Default PS...
    Your instincts are correct. CMS guidelines say that "MDM should be the overarching criterion when selecting the E/M level", so it carries a significant amount of weight, even when the history and exam would point to a higher code.

  6. #6
    Default
    You did a wonderful job explaining! Thank you this is exactly what I thought as well.

    Have a great day!

    Raechel

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