# 99212 or 99213



## HBULLOCK (Jul 20, 2010)

We have a patient who came in with an arm injury. The nurse did temp, bp and weight.  HPI states played multiple sports this w/e, very sore yesterday and this am, better now but still sore over distal femur with flexion. 
Works construction using nail gun daily right hand. 

PE:  Gen appearance wdwn, nad
      Extremity: r elbow sl swollen over dorsum of r humerus/triceps tendon with ttp, FROM with some stiffness on full flexion, equal hand grasps. 
      Neuro: neuro circ intact distally

Assessment: tendonitis R tricep

Plan: rest, ice, ibuprofen

To me this looks like a 99212 since mdm is straightforward. Doctor wants me to bill 99213.  What do you think????  thanks


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## ohn0disaster (Jul 20, 2010)

I agree with you. To me, this looks to be 99212. My doctors often check off an E/M code on our encounters. I ignore it and make my own decisions when it comes down to it.


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## HBULLOCK (Jul 20, 2010)

*99212/99213*

Thanks Vanessa. That's what I thought. I'm going to go back to him and show him why it's a 99212 and not a 99213 for his future reference.


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## sgoodknight (Jul 20, 2010)

Something else to consider?

The nature of the presenting problem (page 7 of CPT)

All depends on where you place it (self-limited or minor/low severity).

Just my two cents.

Sandy


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## ecevans (Jul 20, 2010)

*99213*

Helen,
These are my thoughts. I agree with the provider.

HPI - 4 elements (timing, duration, context, location)

Ros-1 (Musculoskeletal)-sore over distal femur with flexion

Exam-Problem-focused (5 elements)

MDM-Low -over-the-counter meds (Ibuprofen)


E Evans, CPC


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## Pamela Martinez (Jul 20, 2010)

*P. Scully, CPC*

I completely agree with E. Evans - a perfect E&M analysis for 99213 remibursement.


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## HBULLOCK (Jul 21, 2010)

*99212/99213*

Just because the doctor told him to take an ibuprofen that makes it a low complexity mdm? There are no chronic illnesses listed, not 2 or more limited/minor problems or even an acute injury.  I think this is a self limited minor problem but he did tell the patient to use ibuprofen for the pain so that makes it ok to bill 99213??  just wanted to clarify!  thanks for everyones input


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## ohn0disaster (Jul 22, 2010)

There are e/m audit worksheets that you can get that will help you with this. I wish I had saved the link on my work computer when I had internet access. Our company blocks just about everything on our computers so I can't even google it but I'm sure you can find it. I went ahead and plugged the info given, from your note, into the worksheet that I have and I still get a 99212....


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## dballard2004 (Jul 22, 2010)

I get a 99213.  I get an EPF history (4 elements of HPI, 1 ROS, 1 PFSH), and PF exam and the MDM is low complexity.  If you want to look at the points:  3 points for a new problem to provider, 0 points for data, and the risk is low because of the nature of the presenting problem.  It is an acute, uncomplicated injury.  You would also get low risk for the OTC meds.  

Just my two cents!


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## cfullum (Jul 22, 2010)

I too get a 99213. You only need 2 of the three components so you don't even need the MDM, you can get it from your HPI and exam.


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## preserene (Jul 23, 2010)

HPI   -1-3, -   Expanded problem focused;   (if 4+-   Detailed)
ROS    1    -   Expanded  Problem focused      
PFSH-   pertinent 1  -   Detailed
So the choice goes to the lowest history level
History  Level  …………………………….Expanded Problem focused.

PE-  Constitutional 1 +  BA 1 = 2…  Expanded problem focused Examination

MDM-  Limited data  reviewed and low risk to the patient of complications or death , if untreated-  this fits in for this patient evaluation for MDM- that places the MDM complexity level- LOW

2 out of 3 KC is enough to code . But her all 3  Key Components  are met with.

Hence it fits very well into the CODE  99213

No way, it can be taken to/reduced to the lower level code of  99212


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## Walker22 (Jul 23, 2010)

cfullum said:


> I too get a 99213. You only need 2 of the three components so you don't even need the MDM, you can get it from your HPI and exam.



That may be true strictly from a CPT perspective, but if the MDM doesn't justify the higher level, then the whole thing could be denied as not medically necessary. MDM should always be the overriding indicator when choosing an E&M code.


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## LindaEV (Jul 23, 2010)

Walker22 said:


> That may be true strictly from a CPT perspective, but if the MDM doesn't justify the higher level, then the whole thing could be denied as not medically necessary. MDM should always be the overriding indicator when choosing an E&M code.



True..._but_ in this case there is a MDM of LOW=99213. I agree with the doctor.

Linda, CPC, CEMC


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## yankeegirl0919 (Aug 11, 2010)

always base your coding off MDM


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