# e&m level 5



## ssharp (Aug 5, 2013)

We had a patient come into the office with a very extensive list of problems. There is a complete history done on the patient the dr has listed up to 21 dx codes that he considers comorbidities but only one dx code is the reason for the surgical new patient visit. The Dr only put the one dx code on the office visit. Should he atleast list 3 more for the claim or would the office notes support the coding?


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## kbartrom (Aug 5, 2013)

The provider may list all diagnoses that impacted her/his medical decision making.  The documentation must support all diagnoses listed.  For a new patient level 5 the documentation must also contain a comprehensive history, comprehensive exam and high complexity medical decision making.  Unfortunately even 21 comorbidities is no guarantee that MDM is high.


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## MikeEnos (Aug 6, 2013)

Exactly, I get a lot of docs who just list 1 diagnosis, but their note addresses multiple comorbidities that factor into their decision making.  Those diagnosis codes should all be reported as secondary, tertiary, etc.  

Also, like kbartrom said, there is no guaruntee that 21 comorbidities will equate to high complexity medical decision making.  However, it almost certainly would justify a comprehensive history and exam - which would satisfy the requirements for a 99215.  You also have the option of having him document the total length of the encounter, and if greater than half was spent face to face with the patient counseling them and/or coordinating care, then the visit can be coded a 99215 based on the time spent (so long as the total time was 40 minutes.)


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