Primary Care Coding Alert

Question: Our provider diagnosed an established patient with nasal vestibulitis and prescribed mupirocin. Even though this is a diagnosed problem, can it be classified as an “undiagnosed new problem with uncertain prognosis” and rise to the moderate level under the number and complexity of problems addressed at the encounter element of medical decision making (MDM)?

AAPC Forum Participant

Answer: The diagnosis would qualify as an undiagnosed new problem, as the problem was undiagnosed at the time the patient presented.

CPT^® guidelines define “undiagnosed new problem with uncertain prognosis” as “a problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.” Such problems are assigned a moderate level of risk; however, undiagnosed new problems do not automatically rise to this MDM risk level.

Even though nasal vestibulitis, a bacterial infection of the nasal vestibule coded to J34.89 (Other specified disorders of nose and nasal sinuses), is a condition that can occasionally lead to serious or life-threatening complications, there is low risk of morbidity and little to no risk of mortality with treatment. This better fits the definition of an acute, uncomplicated illness or injury — a step below the moderate MDM risk level. CPT^® guidelines define such a condition as a “recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.”

So, an acute, uncomplicated illness or injury is associated with a low level of MDM for the number and complexity of problems addressed element. As the provider has opted to treat the condition with prescription antibiotics, you have a moderate level of risk under the risk of complications and/ or morbidity or mortality of patient management element of MDM. Assuming your provider had minimal or no data to review, the amount and/or complexity of data to be reviewed and analyzed element would be minimal or none, which is consistent with straightforward MDM.

Per CPT^®, the level of MDM for office/outpatient evaluation and management (E/M) services is based on two out of the three elements of MDM meeting or exceeding the element level. In the end, this would give you a low MDM level, enabling you to document 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. …) for the encounter.