Wiki E/M ? - Provider orders x-ray, but no additional MDM.

[daphneb0226]

I code for a walk-in clinic and we have an NP who feels that the E/M code should be a 99213 when she sees (for example) an established patient that presents with foot pain. The NP will order an x-ray which shows no abnormality; no additional work-up is performed and the documentation just states "reviewed". I feel that a 99213 is a stretch considering the limited amount of documentation. Additional thoughts and advice is greatly appreciated!

 

[jkyles]

Hi there, if I'm understanding this correctly I think it would be hard to get this to a level 2 visit with element-based coding. There's no way to tell either the complexity of the problem addressed or the risk unless the provider writes something down and she only ordered one test.

 

[csperoni]

With the limited information provided, it's difficult to come to a level.
Problem: likely low (level 3) for acute, uncomplicated illness or injury. Could be minimal. Could be moderate.
Data: minimal/none (level 2). You don't even count the the xray if your same office is performing the xray. The work of ordering the xray when performing it is theoretically built into the value of the xray code.
Risk: depending on treatment plan, could be minimal (level 2) if treatment is rest or bandage. Low (level 3) if OTC meds or PT. Moderate (level 4) if rx ordered.
99212, 99213 and 99214 are all possible depending on the other information not provided.