Hello!
With the new Office Visit leveling guidelines being based on MDM or time alone, what level of EM would you consider the Confirmation Visit to be?
Prior to 2021 EM Leveling guidelines, we could use the history and exam to level the visit, but now that those are not calculated, using just MDM is a little tricky
If the provider documents time, that's easy-peasy. A 30 minute visit would be 99214. I have been encouraging my providers to document their time at these visits.
Without time, I am unsure if the "Number and Complexity of Problems Addressed" is a Low or Moderate level. Would confirmation of pregnancy be considered "1 acute, uncomplicated illness/injury," and so be considered Low, or would it be "1 acute illness with systemic symptoms" and so be Moderate?
The remaining two elements of determining MDM are more straightforward...I consider the Data Element to be Low/Moderate depending on if they order Prenatal Labs, outside Ultrasounds, STI screenings, etc, and if the patient has identified risk factors like Preexisting Diabetes or Hypertension that must be reviewed.
Thank you!
With the new Office Visit leveling guidelines being based on MDM or time alone, what level of EM would you consider the Confirmation Visit to be?
Prior to 2021 EM Leveling guidelines, we could use the history and exam to level the visit, but now that those are not calculated, using just MDM is a little tricky
If the provider documents time, that's easy-peasy. A 30 minute visit would be 99214. I have been encouraging my providers to document their time at these visits.
Without time, I am unsure if the "Number and Complexity of Problems Addressed" is a Low or Moderate level. Would confirmation of pregnancy be considered "1 acute, uncomplicated illness/injury," and so be considered Low, or would it be "1 acute illness with systemic symptoms" and so be Moderate?
The remaining two elements of determining MDM are more straightforward...I consider the Data Element to be Low/Moderate depending on if they order Prenatal Labs, outside Ultrasounds, STI screenings, etc, and if the patient has identified risk factors like Preexisting Diabetes or Hypertension that must be reviewed.
Thank you!