# 99214?



## Bernadette10 (Sep 25, 2019)

Another example:
EPF history, detailed exam, assessment is bilateral acute otitis media and hand foot and mouth disease, both new problems but an established patient.  An antibiotic was prescribed.  Can this be 99214 because of moderate MDM for 6 problem points and moderate risk for the antibiotic, or since these are acute, uncomplicated problems would the risk be low and therefore low MDM?


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## Cls1530 (Sep 30, 2019)

I do not think either one of the diagnosis are uncomplicated problems. Both of them are infections and can cause other problems if left untreated. 

Hope that helps some.


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## dmunoz781 (Oct 25, 2019)

exam is detailed and MDM is moderate wit two new conditions requiring medication treatment risk is moderate, MDM is moderate.  I would capture a 99214 in this scenario.


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## zoinks071 (Oct 26, 2019)

The fact that an antibiotic was prescribed elevates the problem to moderate risk, and I would definitely consider it moderate MD overall. If the infection is significant enough that RX management is involved, it would no longer be considered an "acute, uncomplicated problem". Hope this helps


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## twizzle (Oct 27, 2019)

zoinks071 said:


> The fact that an antibiotic was prescribed elevates the problem to moderate risk, and I would definitely consider it moderate MD overall. If the infection is significant enough that RX management is involved, it would no longer be considered an "acute, uncomplicated problem". Hope this helps


Neither would be considered moderate risk conditions. Hand foot and mouth disease is a mild, non-serious self-limiting condition and OM is an acute uncomplicated illness.
While I agree that any Rx drug management including antibiotics carries risk, the patient's conditions based on medical necessity do not warrant moderate risk (IMHO).
Many organizations now take the direction of not automatically assigning moderate risk for antibiotic/antiviral Rx drug management, instead focusing on what condition(s) the treatment is aimed at.


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## zoinks071 (Oct 28, 2019)

I can see your point, however in this scenario where there are two new problems to the provider who is utilizing the additional mental labor of making the initial diagnoses I maintain that the overall MDM would rise to moderate complexity. If this was a followup visit for these known issues or it was a recurrent problem I could certainly see where a 99213 might be more appropriate.


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## wynonna (Oct 28, 2019)

Also let's remember that minor or self-limited means problem will resolve with OR without treatment or medical intervention.
Examples from E & M worksheet include: cold, insect bite, tinea corporis.  One of these  would be a minimal presenting problem if no OTC or RX management is done.
OTC corresponds to low but Rx/Medication Management corresponds to Moderate keeping medical decision making in mind.


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## Pathos (Oct 29, 2019)

Don't forget that the overarching criterion for any E/M level is Medical Necessity. I think what Twizzle is trying to explain is that even with an RX, you shouldn't automatically assign a Moderate Risk. The reason why CMS is not fully adopting the popular Marshfield Clinic tool, is that the point system is sometimes ambiguous.

https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf


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## twizzle (Oct 29, 2019)

Pathos said:


> Don't forget that the overarching criterion for any E/M level is Medical Necessity. I think what Twizzle is trying to explain is that even with an RX, you shouldn't automatically assign a Moderate Risk. The reason why CMS is not fully adopting the popular Marshfield Clinic tool, is that the point system is sometimes ambiguous.
> 
> https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf


Thank you Pathos. My point entirely. Going back to zoinks071 comments; I think the amount of 'mental labor' as you so succinctly describe it would not be difficult for either condition. They are simple-enough problems to diagnose and on that basis the overall risk is low for this case despite the antibiotics.
The whole 'level of risk' is often down to the client when considering antibiotic/antiviral/steroid cream meds. Some providers feel that any Rx carries risk, as it does. Others see the use of these meds for uncomplicated problems as relatively low risk. I try to assess each case individually due to my clinical background so that changes my thought process somewhat. 
I would not consider OM and H,F,M disease to be as serious as diverticulitis for example but both may require antibiotics. You have to separate the level of risk somehow in order to define medical necessity.


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## Pathos (Oct 29, 2019)

To properly assess the MDM of this visit, I would need to see the whole patient chart. The MDM could be Moderate if the Medical necessity is there. However, if it's just "_vanilla_" OM and HFM disease, then slapping an Abx and call it good, might not agree with a Moderate MDM. What is in the *History*? What about the *Exam*? Is there anything that the patient's condition might be severe enough to warrant a Moderate Risk? I used to work for a provider group who was determined to bill 99214 for most QuickCare/ExpressCare (visits manned by PAs/NPs) just because they included an Rx script. That clinic completely missed the boat on Medical Necessity and they will discover that come RAC audit time.

I think we often tend to get a little pigeon holed when using a quantifiable tool like the Marshfield Clinic tool, because this tool makes auditing the MDM so much easier, that we forget the real trump card; Medical Necessity. Because Medical Necessity is so qualitative and hard to pin down without a fair amount of clinical background, you should probably need to see the whole picture of the patient's conditions, instead of just looking at sections of the chart. Depending on the chart note, I could honestly see this go either way, however I am leaning towards 99213 unless there is something that would convince me that the OM and HFM disease are severe enough to be Moderate.

As a minor detail, if you do follow the Marshfield Clinic Tool, then you cannot assign 6 points for 2 New Problems to the provider w/o additional work-up, as this maxes out at 1 problem. This would instead result in 3 points, which would not sway the overall MDM in either direction, but something to consider.


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