Wiki Established patient visit

[prirs1985]

2 out 3 key components are required for established pt visit. Can we assign higher level code (e.g 99215) base on comprehensive history and comprehensive exam? Please advice.

 

[mitchellde]

Coding in a vacuum yes you would do that. However you must look at logic. What is the diagnosis? Did this pAtient’s diagnosis require the intensive service of a level 5 visit? Just because you can see a level 5 visit from the key components, should all those point be counted as relevant due to the diagnosis. How much of that note was “mailed in”? A comprehensive history is many times cut and pasted from a previous note! How much of that examination is relevant to the patient diagnosis vs how much was just checks on a template. If the exam required all the elements of a level 5 then why did the medical decision making not make the grade?
Remember medical necessity is the most important factor. Just because you can put comprehensive elements in a visit note, SHOULD you do that.

 

[snoprean]

That is a great point you bring up. We are having issues trying to get our Endocrine provider's level for their established patient above a 99213. Since we follow the 2 out of 3 rule with the exception that one of the 2 should be MDM this does hurt their levels. A common scenario is an est patient comes in for follow up on T2DM that is not controlled. The provider reviews their BS journal and checks it in the clinic and it is over 500. They give the patient aspart 10 u and repeat the BS and order some additional tests.
This patient has T2DM with severe exacerbation but we still only get 2 problem points for Est Worsening, 1 data point for lab and High level of Risk. This is still a low MDM