# E/M pain clinic questions



## Christine72 (Jan 22, 2014)

I work for a large anesthesia practice where we have pain clinics. I want to do my best at E/M coding. I have different people telling me different things to some of my questions. I'm taking the online E/M coding lesson through the AAPC but I'm overwhelming myself.

The main 2 things in most of my visits are that they are going to change the dosage and/or med to something else. The other is lab work. They are going to a UDS.

1. Patient A is an established patient coming in for their routine Rx visit. They have no new complaints and the NP in our practice writes "continue meds as prescribed" or "no med changes".  Let's say the med is a narcotic. The patient has been on this same med and dosage for awhile.  My thinking is since there are no changes I should  code this a 99212 or "because" it is a narcotic and the "table of risk" has "prescription drug management" under "moderate" I should use a 99213?

What I'm trying to ask is this. Because the patient is seen monthly for prescription drug management, of a narcotic, would this make my E/M level 99213? I asked my own primary care MD when I was at my own check up what his opinion was. He said a 99212 if no changes. 

Please give me feedback. Make it simple for me because my head is spinning from working so hard at reading and doubting my thoughts.


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## dwaldman (Jan 23, 2014)

http://www.emuniversity.com/index.html

Above from Peter R. Jensen MD, CPC is great resource for E/M coding that I reference a lot and have taken the courses he offers. The AAPC also offers some great courses and webinars for understanding the always complex E/M code selections.

I agree with your physician if the patient is coming in and the plan is continue with present treatment plan with no refill nor adjustment or new medication. A level 2 would seems reasonable.

For patient with a refill. I would ensure if you are looking at a dictated note, that there is a ROS of at least one  system  (problem pertinent) is documented for the level 3 and depending on which physical exam guidelines you follow that these elements are met.

If you are using an EHR. there might be more documentation such a larger past social family history and ROS. Potentially more detailed information for obtaining quality measures. Regardless, no refill no procedure or other treatment planed. Just stating continue present treatment plan sounds like a level 2.


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## dwaldman (Jan 23, 2014)

Here is a 99213 versus 99212 example from EM university.

99213
An established office patient with osteoarthritis

CC : ? knee pain.?

Interval History : Patient with known osteoarthritis which had been previously controlled on Tylenol.  Now states his left knee has been aching for about two weeks despite two to three doses of Tylenol per day. 

ROS :  Musculoskeletal--Negative for arthralgias or worsening joint pain elsewhere

Physical Exam

 Mild swelling of left knee compared to the right.  Some pain with passive rotation.  No overlying warmth or erythema.

Assessment
1.Worsening osteoarthritis
Plan 1.Start OTC ibuprofen 400 mg po TID, PRN
2. Return visit in two weeks if no improvement


99212


An otherwise healthy established office patient with a cold

CC : ? Cough and congestion.?

Interval History : Patient states he developed nasal congestion and a runny nose about five days ago.  More recently, these symptoms have been associated with a non-productive cough. 


Physical Ex am

 General appearance: No acute distress; conversant 
 Vitals: 98.6, 72, 20, 110/74 
 HEENT: Oropharynx is clear with normal posterior pharynx without erythema or exudate. Lungs: CTA

Assessment
1. Common cold
Plan 1.Push fluids
2.Rest
3.Tylenol, if needed


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## dwaldman (Jan 23, 2014)

(Only two out of three elements are required) 

Overall MDM   Problem Points   Data Points   Risk 
Straightforward            1                  1          Minimal 
Low complexity              2                  2         Low 
Moderate Complexity      3                 3          Moderate 
High Complexity           4                 4           High 


I guess the last thing I can think of regarding your question. You seem to be reviewing the MDM and above is the point system that can be used to determine the MDM. Which puts a numeric value to minimal, multiple etc.. And looks at the problems as stable or worsening. New or Established. 

In your example, you didn't state how many conditions the patient is presenting with. Opioid drug management would fall under moderate risk, but one stable condition would not meet a level 3 from a MDM standpoint. Also the exam and history for one stable condition could also be reviewed. Additionally the time spent and counseling component or coordination care for 10 minutes for a level 2 to 15 minutes for a level 3, this accounted for more than 50 minutes of the time spent.

I tried to answer the best way I could. You could also review the clinical examples and their corresponding levels in the back of the AMA professional CPT manual. Which does have some pain management examples. I guess I can say it not easy just to state that your example is all just one level since documentation and patient needs can vary.


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## dwaldman (Jan 23, 2014)

I might 50 percent of the time spent


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