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Thread: Where does a 99213 come from?

  1. #1

    Question Where does a 99213 come from?

    AAPC: Back to School
    Im looking at how I would explain a 99213 if I were to have to defend it in court.

    Case- A patient comes in with a new problem of OM (no other problems) & the provider prescribes an antibiotic.

    Question- If the only two options are self limited/minor or New problem. How do people get a 99213 (assuming the HPI or Exam are detailed W/ no data)?
    On an auditor sheet, self limited/minor = 1 point and New Prob w/o wrkup= 3 points. If I choose self limited/minor, I can only get a 99212, if I choose New Prob w/o wrkup, I get 99214.

  2. #2
    Join Date
    Apr 2007
    Evansville Indiana

    Default 99213

    Just because the "points" add up to 99214 does not mean that the medical necessity is there for that level. If it is a simple OM with prescription it would not warrant a 99214. Medical necessity should always be the deciding factor for determining a level when all other elements are met.

  3. #3


    Doesn't giving a prescription antibiotic (which is like saying the condition cannot run its course without extra treatment) warent the medical necessity for a 99214 (as long as the HPI or Exam back it up)? If not, what would medical necessity of a 99214 be?

  4. #4
    Join Date
    Apr 2007
    Evansville Indiana

    Default 99213

    The nature of the presenting problem along with the patients co-morbidities determines the medical necessity of a visit. The fact that a prescription medicine is given does not mean that the medical necessity warrants a 99214. Giving a simple antibiotic for an ear infection with no co-morbidities is not as complex or risky as managing meds for a diabetic, hypertensive person who comes in with an earache.


  5. #5
    Join Date
    Apr 2007

    Default There is no clear cut answer to your question

    I have no problem saying OM with a Rx can support a 99214 if you have the history or exam in addition to the MDM to support the level. OM is a new problem no work up and antibiotics qualify for Rx management.

    But lets say the MDM is low or even straight forward, if this is a return for the same problem it would/could be. Established visits are 2 of 3, so the level could be determined by history and exam. A 99213 requires any 2 of the 3 key components to meet or exceede an expanded problem focused history, expanded problem focused exam, and mdm of low.

    Medical necessity is the driving factor but MDM is not the determining factor for establishing medical necessity. It is a pretty good general guide but it is not the end all be all.

    We have our providers go thru Dr. Jensens presentation on emuniversity. They are nice presentations but I always caution them that just because the MDM points to a certain level does not make the other components needed to support this level medically necessary. The same is true in reverse. Just because the MDM doesn't support a level ( in established visits) doesn't mean that that is not what is medically necesary to take care of the patient.

    You also need to keep in mind the point system we use to determine MDM is not part of the official guidelines.

    Just my opinion,

    Laura, CPC, CPMA, CEMC

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