# MDM level - Could someone help me with this one



## dsmith06351 (Mar 25, 2009)

Could someone help me with this one. I am looking for help with the risk of complications. This is a 2 month old baby with laryngomalacia. On this visit the Dr did a detailed HPI and a detailed exam.

The dx is stridor with new apmea spells over last 3 days, increased emesis

The Plan is to admit for evaluationa nd observation and hopefully ENT and GI evaluation to help stabalize respiratory satus. will send via ambulance. 

We are not the admitting physician. How would you define the risk of complications? 

Thanks for any help. 

Denise CPC-A


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## LLovett (Mar 26, 2009)

I would be tempted to say high on this one. You have a chronic illness (laryngomalacia) with severe exacerbation (stridor, apnea, and emesis). Some may argue it is not severe but the fact that it could be life threatening to me qualifies as severe. 

On the flip side though, you say that there is a detailed exam and detailed history so whatever code you are looking at will be limited to what is supported by detailed, whether it is a 2 of 3 or 3 of 3 code.


Just my take on it,

Laura, CPC


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## ARCPC9491 (Mar 26, 2009)

Laryngomalacia is a common, but serious condition in infants, as it blocks the airways. It can lead to stridor, which is very serious and can pose a threat to life if not treated emergently. To me, it seems like the laryngomalacia is exacerbating <given the stridor, apnea, emesis> and I would consider this *HIGH RISK* "illness with threat to life or bodily function"

So overall, you would have a MDM of HIGH

If this is a NEW problem....
I would consider it to be new prob w/ work up... 4 points

and you say the provider documented a detailed history and exam, so the level, if this patient is new, would be 99203 and if the patient is established, it would be 99214.

Hope that helps...


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## Lisa Bledsoe (Mar 26, 2009)

I agree with the above posts.  Since the illness is possibly life threatening, I would definately consider it high risk.


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## dsmith06351 (Mar 26, 2009)

Thank You to all that have responded. I came up with the same answer. I am trying to learn as much about E/M coding as I can. I am studying for the CEMC. 

Now let me ask another question. The Dr spent a total of 1 hour with the patient. Because the levels for the HPI and exam are detailed the code is 99214 can I also use the prolonged service code based on the extra face to face time?


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## ARCPC9491 (Mar 26, 2009)

Did the doc document that he spent 1 hr and more than 50% counseling/coordinating care was spent face to face? If so, you could _actually bill 99215.  _

You should not bill prolonged services, 99354, unless it was atleast an hour above and beyond the usual service....


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## dsmith06351 (Mar 26, 2009)

I understood 99354 can be used for 30-74 minutes. Am I reading something wrong? I have used this code before mostly when the doctors are performing nebulizer treatments and the level of care does not match the time spent. 

Denise CPC-A


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## ARCPC9491 (Mar 26, 2009)

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf

So one hour beyond the usual service.. say 99215 (40 min) would be 70 minutes..

I wasn't very clear and I apologize for that...... you COULD bill 99215 if the time is documented appropriately...

you also could bill 99214 (if time wasn't the determining factor) with 99354... the threshold time to bill 99354 would be 55 minutes...


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## FTessaBartels (Mar 26, 2009)

*Critical Care*

Just to throw out another consideration.

If the patient is critically ill (sounds like it to me), and the care provided is critical care (i.e. stablizing patient in preparation for ambulance transfer to hospital), and you have at least 30 minutes of said care (you have 1 hour documented), then you can code 99291.

Otherwise, yes, you can code the 99214 plus 99354.

F Tessa Bartels, CPC, CEMC


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