Wiki 6 month follow-up for surgery - 99212?

[Yjrieken]

I have a question concerning the level of E/M visit for a 6-month post-op visit. Surgery was rotator cuff repair. Patient is doing well, no issues. shoulder was examined for ROM, etc... Plan is to come back as needed. The physicians are wanting to charge a 99213 for these visits, but I feel that based on MDM, it should be a 99212. Any feedback would be appreciated. I have recently took over some ortho coding for a specialty clinic and do not want to make the mistake of coding a higher level. Thank you!

 

[csperoni]

Let's break it down to problem, data, and risk.
Data is nothing, so minimal or none - level 2.
Risk of complications/morbidity/mortality of treatment. If no PT, or meds (OTC or Rx), then I would have to call that risk level 2 as well.
So whether you consider the rotator cuff injury as a stable acute illness (level 3), or minor (since it's now seemingly resolved) (level 2) is a moot point.
If the physicians are expecting 99213, they need to document medical decision making that meets level 3. Based on the information you provided, it is not currently documented.
It is very possible the physicians are telling the patient to take aleve or ibuprofen prn, or discuss why they don't see a need for additional PT. But if it's not being documented, you cannot count it. The switch in 2021 to medical decision making only makes it more important than ever for clinicians to adequately document the thought process in their head. The thought process IS the medical decision making.
To say every rotator cuff follow up is any given level would be incorrect. Each patient's encounter needs to be evaluated by the documentation. Someone with a resolved problem and no further treatment or testing would typically be 99212. But some patients may not be improved, but not fully resolved. Or may need further treatment or testing. I could see those being 99213 or even 99214. It's all in the documentation.

 

[amyjph]

I agree with Christine on all points. Each encounter has to be taken separately and leveled according to the documentation. We can't just say, okay every RCR follow up out of the global is a 3 or 2, etc. We would have to see the specific documentation to know 100%. I can see why providers might think 3 though, because in 95/97 they probably were. You could get 2/3 EPF/EPF/Low easily for that type ortho visit before.

While many orthopedic office visits end up being higher levels than prior to 2021, I have found there are a number, where if you were to code them both ways, it ends up lower according to 2021. This is probably one of those type. But, it makes sense. If it's the "You're doing great, come back PRN!" type. Like Christine said, resolved, surgery was a success, no issues, no data, risk is minimal to none.

There are many times RCR recovery is much more complicated and lengthy especially if it was a massive tear of more than one tendon/muscle, they did other work at the same time, the patient's age, they have co-morbid conditions, etc. Some patients are still in PT, on meds, and struggling at 6 months. That would be totally different.