Primary Care Coding Alert

Question: A patient had labs drawn and came back in to review the results. Upon review, the practitioner diagnosed the patient with hyperlipidemia and hyperthyroidism, of which the patient has no prior history. The practitioner is going to monitor and recheck lab levels in one month. How do I categorize those problems? This scenario doesn’t seem to fall under any of the definitions in the number and complexity element column for medical decision making (MDM).

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Answer: This encounter does not neatly fit into either a low or moderate level, but probably aligns best with office/outpatient evaluation and management (E/M) service 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making…). Here’s why.

Hyperlipidemia and hyperthyroidism are both generally considered chronic conditions, which immediately suggests a moderate level of MDM in terms of the number and complexity of problems addressed element. But according to the Guidelines for Office or Other Outpatient E/M Services, the word “stable” implies the patient has reached the treatment goal for the condition. This cannot be the case in a patient with new diagnoses.

Additionally, the visit does not meet or exceed the requirements of the of data to be reviewed and analyzed element of the MDM table at the moderate level. The practitioner may have reviewed prior external notes from each unique source, but that hasn’t been documented and therefore cannot be assumed. The practitioner did review test results and order new tests, but the number involved is unknown, so it’s unclear whether that satisfies the Category 1 requirements. The provider did not note an independent historian, nor the independent interpretation of a test performed by another physician/other qualified healthcare professional (QHP), the latter of the Category 2 requirements for this element at a moderate level.

There is also no mention of the provider managing prescription drugs, a provider decision for minor or major surgery, or the provider deciding that patient treatment will be significantly limited by any social determinants of health (SDoH), all of which are examples of moderate risk. So, without additional information, there’s nothing to suggest a moderate level of risk of morbidity either.

Putting it all together: The provider has identified two chronic illnesses, which exceeds the requirements for number and complexity of problems addressed at a level three office/outpatient visit. The provider has ordered one or more unique tests, but without knowing how many, one can’t say whether the data element requirements for a limited data level of MDM have been met, and again, there’s no reference to an independent historian. From a risk standpoint, the conditions themselves and the routine nature of the blood tests present a low risk of morbidity, which satisfies a low level of MDM associated with a level three office/outpatient visit. Consequently, this encounter meets or exceeds at least two of the three requirements of low-level MDM but doesn’t quite meet any of the requirements for moderate MDM, thus making 99213 the best choice.