Wiki level 2 or 3 for overall E/M?

[wynonna]

Regarding outpatient E/M, 2021 guidelines:
HPI
Patient returns in follow-up for his slightly asymmetric sensorineural hearing loss and bilateral tinnitus. He is not aware of a change in his hearing. There is no change in his bilateral tinnitus which sometimes interferes with sleep. He does try masking with television. He has had occasional slight dizziness but none in more than a year. He has extensive history of occupational noise exposure and has had numerous occupational audiograms that showed the left being worse than the right.

Assessment and Plan
(1) Asymmetrical sensorineural hearing loss:
Plan:
Impression: Relatively stable mildly asymmetric sensorineural hearing loss

Plan: Repeat audiogram 1 year, importance emphasized, unlikely risk of acoustic neuroma mentioned
(2) Tinnitus of both ears:
Plan:
Tinnitus masking is discussed

Exam is problem focused.

Bill 99212, or 99213?

 

[csperoni]

Where are you having confusion? Try providing your leveling in each of the 3 elements of MDM so we can help figure where you are stuck and provide guidance.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

 

[OpenClaims]

I would say that this qualifies as a 99212. Tinnitus and SNHL (2 self-limited problems), 1 test ordered, minimal risk. Two out of these three fall under the level 2 category, which would leave you to choose a level 2.

 

[csperoni]

I would say that this qualifies as a 99213. Tinnitus and SNHL (2 self-limited problems), 1 test ordered, minimal risk. Two out of these three fall under the level 3 category, which would leave you to choose a level 3.

Please explain your response further.
By your own posting:
Problem - 2 self limited - low = level 3
Data - 1 test - minimal or none = level 2
Risk - minimal risk = level 2
I don't understand how you arrive at 99213.

 

[OpenClaims]

Please explain your response further.
By your own posting:
Problem - 2 self limited - low = level 3
Data - 1 test - minimal or none = level 2
Risk - minimal risk = level 2
I don't understand how you arrive at 99213.

Here is a link to a helpful chart that many employers ask their coders to use for leveling out E/M. I misread that there was only 1 test ordered. This would qualify as a level 2 with only 1 test being ordered.

E/M Grid