Wiki MDM for Total Hip / Knee Replacement

[KStaten]

Hello Everyone. I have gone down a rabbit hole on coding joint replacement surgeries and would GREATLY APPRECIATE your input for confirmation, given the 2021 E/M guidelines. I apologize in advance for the redundancy of this question.

A ) In the plan, it is documented that a 65-year-old established patient presents with a history of OA of the left hip and she says that she cannot live with the pain. She has tried to modify her activities, medication, therapy, and injections to no avail. The patient wishes to proceed with surgery. The doctor discusses the standard risks of total hip replacement, including embolism, loss of blood, component failure and, thus, the risk of a repeat surgery, and even potential death. (The doctor does not mention any other health problems and /or does NOT discuss how other health conditions may factor into putting the patient at increased risk.) The patient wishes to proceed with the surgery and the doctor presents her with a surgery handbook and begins the scheduling process.
E/M Level:______________

B ) The same patient returns after getting routine clearance from her PCP for the total hip replacement two weeks before the scheduled surgery. The doctor answers any questions the patient may have about the upcoming surgery.
E/M Level (if applicable):______________

C ) The same patient returns in 4 months (outside of 90-day-global period) as a routine follow-up visit. The doctor documents the entirety of the plan as, "The patient returns and is doing well. I plan to see her in 1 year." No mention of medication, therapy, etc nor any mention of reviewing any data.
E/M Level:______________

THANK YOU!
Kim

 

[csperoni]

Here's how I would code these with rationale breakdown:
A) Problem: chronic with severe progression, level 5
Data: none, level 2. Please note it would be very uncommon for my surgeons to not order PST labwork, EKG, etc and would usually be level 4. Your surgeon may do things differently.
Risk: decision regarding major sx with identified procedure risk factors, level 5
Final: 99215
B) What was the medical necessity for this visit? If surgery was already discussed and decided, not sure why patient is there again. IF there was medical necessity, possibly a level 2. I personally would count this as included in the global surgical package. Please note my surgeons would not have the patient return unless the patient changed her mind or a different surgery is being decided. If the patient did have some questions regarding surgery, they would call and speak with a clinical staff member (not the physician unless very rare circumstance). Again, your surgeon may do things differently, but still needs medical necessity to possibly be billable.
Final: part of global surgical package not billable. We have an internal code 99023 for a visit such as this.
C) Problem: chronic stable, level 3
Data: none, level 2
Risk: minimal, level 2
Final: 99212

 

[KStaten]

Here's how I would code these with rationale breakdown:
A) Problem: chronic with severe progression, level 5
Data: none, level 2. Please note it would be very uncommon for my surgeons to not order PST labwork, EKG, etc and would usually be level 4. Your surgeon may do things differently.
Risk: decision regarding major sx with identified procedure risk factors, level 5
Final: 99215
B) What was the medical necessity for this visit? If surgery was already discussed and decided, not sure why patient is there again. IF there was medical necessity, possibly a level 2. I personally would count this as included in the global surgical package. Please note my surgeons would not have the patient return unless the patient changed her mind or a different surgery is being decided. If the patient did have some questions regarding surgery, they would call and speak with a clinical staff member (not the physician unless very rare circumstance). Again, your surgeon may do things differently, but still needs medical necessity to possibly be billable.
Final: part of global surgical package not billable. We have an internal code 99023 for a visit such as this.
C) Problem: chronic stable, level 3
Data: none, level 2
Risk: minimal, level 2
Final: 99212

Ahhh! Thank you very much! You confirmed the thoughts that led me down the rabbit hole. I had initially been questioned as to why Scenario C was coded as a Level 2 and not a Level 3, and, luckily, my thought process was the same as yours. There is clearly not enough to support the Level 3.

As for Scenario A... As I was researching evidence for why Scenario C could only meet a Level 2, I began to realize that with the 2021 Guidelines, encounters for decision for a hip replacement would meet the criteria for Level 5, as you have also pointed out. As long as the doctor documents that 1) the patient has exhausted other treatments, 2) the patient's quality of life / daily activities have been affected, and 3) the condition has progressed, then that should meet the first Column of the MDM table (Problem... of "High complexity"; one or more chronic illnesses with severe exacerbation or progression). And, considering that the standard risks of major total hip replacement, include embolism, loss of blood, component failure and, thus, the risk of a repeat surgery, and even potential death, then that should meet the last column for the Level 5, "Risks of Complications, Morbidity or Mortality of Patient Management; decision regarding elective major surgery with identified patient or procedure risk factors.

So, I'm thinking/typing out loud here.... Theoretically, if a patient is having a major joint replacement, then medical necessity should always meet the first column of the Level 5 of the MDM table, or else there would be no need for surgery. (But, of course, that means the doctor should always document well enough to prove this.) And... since the potential risks of joint replacement could result in any of the complications I've listed above, then it should always meet the last column of the Level 5 of the MDM table. (?) Does this make sense or am I just overcaffeinated at this point?

Regarding Scenario B... I agree, also. The provider discusses surgery in Visit A and then sends the patient to get clearance for surgery (standard cardiac clearance, bloodwork, etc) from their PCP. If no problems presents during the clearance testing from the PCP, then the provider reviews these results with the patient and answers any questions the patient may have in follow-up Visit B. The conundrum with which I have been faced is, the surgery technically has been discussed, scheduled, and planned in Visit A, and the decision has technically been made to proceed as a default unless something presents itself in Visit B. So, the option could be to either code Visit A as the 99215... and no charge for Visit B with an internal code as you have suggested... OR code a lower level E/M for Visit A (if one argues that the decision hasn't officially been made at this point) and then the Level 5 for Visit B, once it has been officially made after clearance. I think the first option seems to make the most sense...

As always, THANK YOU all for your help and for putting up with my questions. My thought process sometimes loops around makes things more complicated than they need to be. Any further input / suggestions / advice is always appreciated.

Thanks!
Kim

 

[csperoni]

I'll provide some further input regarding your thinking out loud theory. There could be many situations where risk is level 5 for major surgery decision, but the problem does not meet SEVERE exacerbation, progression or side effects. It could very easily be level 4. The phrase "cannot live with the pain" (even though not really quantified) is what leads me to severe progression. Someone could definitely make an argument for level 4 number/complexity of problems in this case. It's just not how I would consider it.
In your Scenario B, if the patient returns and the surgery changes or cancels due to other medical problems, then that could easily be justified as a billable visit. Otherwise, the decision was made at the first visit and I do not see medical necessity for the second.
Here's a real world example where you could have 2 billable visits:
Patient has severe epilepsy and we are evaluating an ovarian cyst. Due to the size/symptoms if the patient did not have epilepsy, physician would recommend laparoscopic removal, but is very concerned about the epilepsy. Asks the patient to have an appointment with her neurologist to discuss and even see if she could be cleared for surgery. After seeing neuro, returns to discuss. That could very well be 2 level 4 visits. But that's <1% of cases.
Everyone else - come in, decide on surgery (level 4 or 5), answer questions. Go get your PST, go get medical clearance from PCP. Physician does not see the patient again until the morning of surgery, but clinical staff are in contact with patient.

 

[KStaten]

I'll provide some further input regarding your thinking out loud theory. There could be many situations where risk is level 5 for major surgery decision, but the problem does not meet SEVERE exacerbation, progression or side effects. It could very easily be level 4. The phrase "cannot live with the pain" (even though not really quantified) is what leads me to severe progression. Someone could definitely make an argument for level 4 number/complexity of problems in this case. It's just not how I would consider it.
In your Scenario B, if the patient returns and the surgery changes or cancels due to other medical problems, then that could easily be justified as a billable visit. Otherwise, the decision was made at the first visit and I do not see medical necessity for the second.
Here's a real world example where you could have 2 billable visits:
Patient has severe epilepsy and we are evaluating an ovarian cyst. Due to the size/symptoms if the patient did not have epilepsy, physician would recommend laparoscopic removal, but is very concerned about the epilepsy. Asks the patient to have an appointment with her neurologist to discuss and even see if she could be cleared for surgery. After seeing neuro, returns to discuss. That could very well be 2 level 4 visits. But that's <1% of cases.
Everyone else - come in, decide on surgery (level 4 or 5), answer questions. Go get your PST, go get medical clearance from PCP. Physician does not see the patient again until the morning of surgery, but clinical staff are in contact with patient.

Thank you very much! You have gone above and beyond to be helpful. On average, I had viewed most encounters for these types of surgeries as Level 4's, but, as I had stated, upon further research, was beginning to see that they could potentially, in fact, meet a Level 5, as you have pointed out. I can see where the patient merely saying that they "cannot live with the pain," could go into the gray area, whereas we all know that there are some patients who would also say that about a minor hangnail and even some who would willingly and readily opt for surgery for said hangnail. IF, however, the doctor states that the patient has "severe osteoarthritis," and the only option for treatment is surgical intervention, then I think one could justify that the problem meets the severe exacerbation, progression, etc.

Your expansion upon Scenario B was also extremely helpful, by the way! Thank you!