Wiki Is this a 99204?

Create Wiki
R

RebeccaMoney

Expert
Messages
292
Location
LEES SUMMIT, MO
Best answers
0
Provider wants 99204 because several body parts examined. I'm leaning more towards 99203 because no surgery discussed nor prescription ordered. EMG is the only thing being ordered. What do you think? Office note attached.
 

Attachments

  • 99204.pdf
    62.9 KB · Views: 5
Here is a suggestion when posting this type E/M level question. Use an audit sheet when coding and to explain why you would choose a certain level. If you break it down it will be easier to decide. "Several body parts examined" is not necessarily an indicator of the level. It "might" mean more work equating to a higher level, but not always. The provider may also mistakenly think they are going to get credit for the interpretation of the X-Rays however, these are documented as his office separately reporting so he can't take double credit in the E/M. The provider is going to examine other areas because of the nerve symptoms (numb/tingling) and they most always do general appearance and at least skin in this type presenting problem. Then, he has a focused exam of the wrist and elbow with positive Tinel's at the cubital and carpal tunnels. If the provider had ordered a new prescription in this case, it could have pushed it to level 4. When the patient follows up and they probably decide on a cubital/carpal tunnel surgery, then it's going to most likely be a 4. When asking the question, if coding by MDM, format it like below and explain why, it will help you learn and have confidence in defending your choice to a provider. You can also ask them to look at their own note and ask, did you forget to dictate something you did during the visit that we are not seeing here? Is this the whole story of the visit?

New or Established: New
Chief complaint/problem: RT wrist pain/numbness and tingling goes up to elbow.
COPA: Moderate (Chronic w/ exacerbation). Doesn't really seem acute since no injury, and it's most likely cubital tunnel. I can't see the service date but it appears this has been going on for a number of months from the note.
Data: Minimal. Order EMG/NCS and Ultrasound (2 Tests).
Risk: Low
Level: 99203

 
amyjph said:
Here is a suggestion when posting this type E/M level question. Use an audit sheet when coding and to explain why you would choose a certain level. If you break it down it will be easier to decide. "Several body parts examined" is not necessarily an indicator of the level. It "might" mean more work equating to a higher level, but not always. The provider may also mistakenly think they are going to get credit for the interpretation of the X-Rays however, these are documented as his office separately reporting so he can't take double credit in the E/M. The provider is going to examine other areas because of the nerve symptoms (numb/tingling) and they most always do general appearance and at least skin in this type presenting problem. Then, he has a focused exam of the wrist and elbow with positive Tinel's at the cubital and carpal tunnels. If the provider had ordered a new prescription in this case, it could have pushed it to level 4. When the patient follows up and they probably decide on a cubital/carpal tunnel surgery, then it's going to most likely be a 4. When asking the question, if coding by MDM, format it like below and explain why, it will help you learn and have confidence in defending your choice to a provider. You can also ask them to look at their own note and ask, did you forget to dictate something you did during the visit that we are not seeing here? Is this the whole story of the visit?

New or Established: New
Chief complaint/problem: RT wrist pain/numbness and tingling goes up to elbow.
COPA: Moderate (Chronic w/ exacerbation). Doesn't really seem acute since no injury, and it's most likely cubital tunnel. I can't see the service date but it appears this has been going on for a number of months from the note.
Data: Minimal. Order EMG/NCS and Ultrasound (2 Tests).
Risk: Low
Level: 99203

Click to expand...
Wonderful explanation and suggestions. Thank you,
 
This is level 3.
Meets Moderate for Condition (chronic w exacerbation/progression), Low for Data Reviewed and Low for Risk of Treatment (referral for EMG/NCS and Ultrasound).
There is zero justification for level 4. Your doc's contention that multiple problems somehow magically equates to level 4 is not supported by the E&M guidelines.
 
You must log in or register to reply here.
Top