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Calling all E&M experts need help!!!

  1. Default Calling all E&M experts need help!!!
    Medical Coding Books
    Hi out there, I need a guide to show me how I should code this visit.

    Established pt comes in for his monthly acne follow up being treated with Accutane. I have a P.A. that I work with that insists that these patients should be coded as a level 4 (99214) every time they are seen. I disagree,
    in regards to E & M and medical decision making, I say this should be coded as a 99212, here is my reasoning...

    A - Amount of diagnosis or treatment options = 1 established problem stable
    B - Level of Risk = moderate for prescription drug mgmt.
    C - Amount of data to be reviewed = 1 for labs reviewed

    Final result for complexity
    A - minimal
    B - moderate
    C - minimal
    99212 - 2 of three meet

    Is this correct?

    Thank you


  2. #2
    Depending on the rest of the documentation, that type of visit would be a 99212 or 99213. Not a 99214 for a routine follow up. The complexity portion of the visit that you describe is a 99212.

  3. Default

    The pt meets a Extended HPI (4 elements meet ), Complete PFSH ( Past , family and social meet), Detailed exam (5-7 body areas are looked at). The dosage of medication is the same (Moderate for pres drug mgmt). Routine labs were reviewed at the time of the visit.

    So based on this the MDM is the driving factor right?

    Number of diagnosis = 1 straightforward
    Risk of complications = moderate
    Amount of data to be reviewed = 1 straightforward

    2 of three need to meet or middle


  4. Default
    Its a level 2 visit. Histoy and PE are detailed but when we are considering a level based on 2/3 components, MDM should be one of them. As MDM is SF for this visit the level is 99212.
    Jagadish, CCS-P, CPC

  5. Default
    Please refer to Letters to Editor section of June 2008 Coding Edge for Dr. Spain's rationale on this.
    Jagadish, CCS-P, CPC

  6. #6
    You don't mention ROS in your post, but hx is based off HPI, PFSH AND ROS. So in order to get your history level, you would need all three of those elements. My guess is that your ROS is 1 for integumentary, so based on what you have posted and that assumption on my behalf, I'd say your history is likely expanded. If that is the case, and your exam is detailed as you state and your MDM is straightforward as you state, your level of service would be a 99213.

    I am looking at my CPT book and nowhere does that or the 1997 Documentation Guidelines specify that MDM MUST be one of the 2 elements counted in leveling, it merely states "requires at least 2 of these 3 key components".

  7. #7
    Atlanta Perimeter Professional Coders
    I agree with you.

  8. Default
    Thank you all for your input, ROS which I did not place into my question, was 2-9 bullets. I have spoken to several coders that agree that MDM is the driving factor for a visit. If your doctor codes a Detailed HPI, Extended ROS, Complete PFSH, and a Detailed Exam and all that was done was destroying a wart and recheck for a rash, why would you code a 99214 based on HX and Exam? No disrepect to anyone just an opinion.

    Thanks everyone!!

    Have a great weekend!

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