99212 vs. 99213

[Brenda1973]

Diagnosis such as cough or nausea are 99212 self-limiting. My question is if over the counter medication is part of the plan to treat the dx of cough or nausea does that bump the MDM up to 99213? My understanding is that if medication (OTC or Rx.) is discussed in the assessment/plan than the cough or nausea is no longer considered "self limiting." Is this correct?

 

[JDACPC]

Diagnosis such as cough or nausea are 99212 self-limiting. My question is if over the counter medication is part of the plan to treat the dx of cough or nausea does that bump the MDM up to 99213? My understanding is that if medication (OTC or Rx.) is discussed in the assessment/plan than the cough or nausea is no longer considered "self limiting." Is this correct?

The OTC/Rx doesn't necessarily change the "self limited" but could change the level of service based on problem addressed, data, and risk. In your scenario, you have the Straightforward problem (self limited), Straightforward data (none), and Low Risk (for the OTC) = 99212. Rx meds are moderate risk so then you have to ask if the documentation supports perhaps an acute, uncomplicated illness instead, but have to look at the whole picture.

 

[csperoni]

I have an issue with stating any specific diagnosis is always a specific level of complexity. Let's use your example of vomiting.
Patient 1 - 14 y/o presenting with mother who vomited once yesterday after watching a disgusting video his friend showed him. No vomiting since, no nausea. Keeping down fluids and light foods. Doc advises to continue light foods for next 24 hours, then resume regular diet. And to stop watching disgusting videos.
Patient 2 - 75 y/o who vomited 7 times over the last 8 hours and unable to keep down any fluids. No nausea. No data/testing ordered or reviewed. Doc advises to proceed to ER for IV fluids and further evaluation. States "concerned about potential dehydration" but does not diagnose dehydration.
Both patients would have a diagnosis of vomiting R11.10, but not the same level of problem.

Don't forget "A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness." So a cough for weeks, and requiring OTC or Rx is likely a more complex problem than straightforward.

For any problem, you have to take the problem as it stands today. Certainly, cough or vomiting may be self-limiting 90% of the time, but could be an acute uncomplicated, acute with systemic, or even possibly an acute that poses a threat to life (but you would expect to have additional diagnoses at that point).
You must level each visit based on the documentation for that visit.

 

[jkyles]

I would just add that the Drs Levy and Hollman have repeatedly communicated that it really does just depend with meds. For example they've said that OTC meds can be low, moderate or even high risk depending on the patient. An example being aspirin form someone on anti-coagulants.