# Mdm? - If the assessment is Cellulitis



## veloso (May 9, 2012)

Hi All,
 If the assessment is Cellulitis and the HPI,PE all Detailed and the MDM Rx. Bactrim and no additional work-up done.
 Would the Level of Service be 99213 or 99214 pls. needs help..

Thanks


----------



## shruthi (May 10, 2012)

veloso said:


> Hi All,
> If the assessment is Cellulitis and the HPI,PE all Detailed and the MDM Rx. Bactrim and no additional work-up done.
> Would the Level of Service be 99213 or 99214 pls. needs help..
> 
> Thanks



For est patient visit, documentation requires 2 of 3 components to be satisfied. Since in your case HPI and PE are both detailed, level will be 99214. (MDM can be moderate or low still level will not change)


----------



## linc11 (May 10, 2012)

I agree with Shruthi, the level is 99214 regardless of your level of MDM.   However, I do prefer that one of the determining factors of the level of the visit be the MDM.  Otherwise we use our judgement and may drop the level of service based on the MDM.


----------



## FTessaBartels (May 11, 2012)

*HISTORY vs HPI*

HPI is only ONE element of *History*

If your HPI is detailed (i.e. 4+ elements (or status of 3 chronic illnesses for 1997 guidelines), you STILL need at least 2 systems in ROS and 1 element of PFSH to qualify for a detailed HISTORY.  (Or 10+ ROS and all three of PFSH for Comprehensive HISTORY).

Now about your MDM
Prescription drug management is moderate RISK, but in order to have a moderate MDM you must also have at least 3 problem points OR at least 3 data points.  Risk, by itself, does not equal MDM.

Hope that helps.

F Tessa Bartels, CPC, CEMC


----------



## veloso (May 11, 2012)

Honestly, I coded it to 99213..a big thanks to all..


----------



## dclark7 (May 11, 2012)

You should also check with your insurance company, some (for instance Anthem of CT) have stated in their policies that they *require* MDM as one of the two elements for established patients the other element can be either Hx or exam.


----------

