Wiki office visit level for ortho visit with MRI order only

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flowergrl

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Anyone else in ortho have providers examining a patient for joint pain, either new or established, and they order an MRI to investigate a joint, and code it 99203-99213?

My thoughts...
Problems addressed - can be either minimal, low or moderate based on the duration and context of the joint injury or pain.
Data to review - if an xray is done in the office and the provider bills for it (technical and professional), can't use it for office visit data. so that's a minimal (none).
Risk of management - provider orders an MRI as management to investigate the joint and determine extent of problem and tx (PT, NSAIDS, surgery, etc). Now technically, this should be used for data... and would count as one unique order which is also minimal for data. But then that leaves nothing for the Risk of Management column, which would also be minimal (such as rest?).

in this case, wouldn't it be a 99202-99212? The provider addressed (documented) nothing that the patient is to do after leaving the office to manage the joint pain. no OTC meds, no therapy, nothing.
Thoughts?
 
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If the joint pain is either chronic, stable or acute, uncomplicated, what you described above seems like level 3.
You state provider is making a decision about PT, NSAIDs, surgery, etc.
PT is typically low risk.
NSAIDs are typically low risk.
Surgery - depends on major/minor and identified patient or procedure risk factors. Could be low, moderate, or high risk.
Any one of those treatment options would result in at least a level 3 visit.
 
To add to what Christine has said. Typically, any patient with joint pain is going to get an X-ray first. If the X-rays are negative, or not correspond to the patient's pain and any other symptoms, the doc will order an MRI to get an idea of what is going on with soft tissue structures. This would "drive up" the MDM.
 
Christine, in the initial message above, I said the provider is NOT making any decision on the treatment, because the provider has no idea the extent of the problem. Until the MRI is done, there is no treatment plan. The provider made no decisions, and documented no advise about what the patient is supposed to do about the joint.

Orthocoderpgu - how does the MRI "drive up" the MDM? The provider gets no office credit for the xray, and ordering one MRI is only considered 1 unique test in the Data column. That is still minimal Data. Please explain further how that would count as a level 3, if there is no treatment discussed for the Risk column.
 
When a patient comes in for any joint pain, the first diagnostic tool is X-ray. X-rays only show bone, not soft tissue. So if a patient who is experiencing pain comes in and the X-rays don't show a clear reason for the pain, like O/A, then the pain is probably being caused by soft tissue which is the reason for the MRI. The provider cannot come up with an accurate treatment plan until they know what's going on. But in this situation, all of the options are being considered by the physician: OTC medications, prescription medications, PT among others. At this point the provider may have a "hunch" based on experience, but needs better info which is the reason for the MRI. Even with MRI, I have seen surgical plans 100% change because the doctor did not find what they expected to find. So reading and interpreting MRI's is not easy. It's not like having a mirror with a clear image of what's going on inside the patient's joint. Keep in mind that the new rules were developed to give the providers credit for MDM depending on the complexity of what is being treated which includes the totality of the situation. At this point the provider knows that bone is probably not involved, now the provider has to see soft tissue structures which are very complex in any joint. That "drives up" the MDM since there are so many options and complex treatment plans.
 
Orthocoderpgu - I now understand your reasoning, however without the documentation in the note that the provider is considering all of these options, and no documentation that the provider discussed any of these possible options based on the pending MRI result, I believe for a coder to make an assumption that the situation is more complex is a mistake. I was taught that coders are not to "read into" the note, or "between the lines" and make assumptions for leveling. I go by whats documented, and none of the situation you described above is documented. It was only stated that an MRI will be ordered. During the next visit when the MRI result is discussed and treatment is discussed, THEN I can use the treatment discussed for leveling.

I understand that a 99202 is the lowest level possible and supposed to be reserved for a "hey, you look good. see you next time" type visit... however what I am saying is the guidelines that are set forth do not provide for this situation to be a 99203 without the documentation to prove it.
 
I'm not asking you to read into the note and never would. If you look at all my posts for the past ten years you will see that I always advocate to code by documentation. This is where doctors and coders need to work together. I have had many conversations with providers over the years and they frequently don't document the totality of their MDM and even key components. As an example, I had a provider who would only document a ROS if it was positive. He was not documenting everything that he was actually doing. I had to help him with his documentation so that it would support the code being billed. Same here. It sounds like the provider is documenting "skeleton" notes to save time. There is no doubt in my mind that given the totality of the circumstances that this is at least a level three visit due to the MDM.
 
No disrespect intended. What you are saying is I need to work with the provider to put more this the note to get to a level 99203. Which supports my point that what is currently in the note is a 99202. There's no doubt in my mind either that it is a level 3, but there's no justification to code it a 3 as it is right now. The office visits that just order an MRI will need to be expanded to include possible future treatments, or at least therapy or OTC med. That answers my question. Thank you.

Working with the provider will take time and repetition to drive home the changes to their current routine, as you well know. Not an easy task. But being a previous nurse that's new to coding, I need to know the definitive reasons and solutions before I approach it, and not be wrong.
 
Orthocoderpgu said:
I'm not asking you to read into the note and never would. If you look at all my posts for the past ten years you will see that I always advocate to code by documentation. This is where doctors and coders need to work together. I have had many conversations with providers over the years and they frequently don't document the totality of their MDM and even key components. As an example, I had a provider who would only document a ROS if it was positive. He was not documenting everything that he was actually doing. I had to help him with his documentation so that it would support the code being billed. Same here. It sounds like the provider is documenting "skeleton" notes to save time. There is no doubt in my mind that given the totality of the circumstances that this is at least a level three visit due to the MDM.
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Absolutely 100% this.
I provided input for PT, NSAIDS, surgery because those items were specifically mentioned in the original post. Regarding risk and data, remember that it is a decision regarding, not necessarily a decision to perform. If currently, the note has no mention of PT, NSAIDs, surgery, etc., then clearly you should not count risk of those items. But it is a great opportunity to educate the clinician if they were considering those treatment plans, but waiting for MRI results, one simply statement like "treatment options of PT, NSAIDs or surgery will be finalized once MRI is performed." clarifies the true complexity of the visit.

Also, if MRI was with contrast, the risk of that alone could be considered low, not minimal.
 
flowergrl said:
No disrespect intended. What you are saying is I need to work with the provider to put more this the note to get to a level 99203. Which supports my point that what is currently in the note is a 99202. There's no doubt in my mind either that it is a level 3, but there's no justification to code it a 3 as it is right now. The office visits that just order an MRI will need to be expanded to include possible future treatments, or at least therapy or OTC med. That answers my question. Thank you.

Working with the provider will take time and repetition to drive home the changes to their current routine, as you well know. Not an easy task. But being a previous nurse that's new to coding, I need to know the definitive reasons and solutions before I approach it, and not be wrong.
Click to expand...
Yes, you need to work with your provider. There is no way that a new patient came complaining of joint pain without X-rays being taken and the provider simply requesting that they get an MRI. Unless the clinics X-ray machine was down, which happens, there is more to this story. If X-rays were taken, why is the provider requesting an MRI? Providers don't go into MRI mode without reason. Christine also gave an excellent response. Right now the documentation probably does not support a 99203, but there is more to the patient's story. Talk to your doctor, I'll bet you will find that there is much more to this than is currently documented. No disrespect taken.
 
Excellent advise. An xray was taken which the provider billed for separately, which was the catalyst for the MRI. But that's where it ended (according to the note). Thank you for the suggestions on possible additions to reach the 99203. I will put together a plan of action and see if we can correct this. In the mean time, will need to deal with each note as they come.
 
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