Wiki Opinion on E/M level

[ckelder]

I have a note that I am torn between a 99212 and a 99213. The provider is stating 99213.
They are correct in that they have to have 2 out of 3 for a established patient but I was taught that the level should not be higher than the MDM. Any opinions on this would be greatly appreciated.

CC: f/u .

History of Present Illness:
PT presents to clinic for follow-up after transition off of Paxil. Feeling well. States ED has improved since cutting down on Paxil. States taking Paxil 20 once daily and Lexapro 10mg ONce daily. Denies anxiety, but states stress level has increased since his girlfriend broke up with him and he recently found out his brother was recently arrested for heroine. Denies any problems.

Risk Factors
Tobacco use: never smoker

Review of Systems
See HPI

Vital Signs:

Patient Profile: 42 Years Old Male
Height: 71 inches (180.34 cm)
Weight: 223 pounds (101.36 kg)
(Measured Weight: 223lbs. oz.)
O2 Sat: 95 %
Temp: 98.2 degrees F (36.8 degrees C) oral
Pulse rate: 93 / minute
Resp: 18 per minute
BP sitting: 127 / 87 (right arm)
Cuff size: large

Pt. in pain? no

Vitals Entered By: ___xxxxxxxxxxxxxxxxxxx____
Do you smoke? No

No Known Allergies
Allergies reviewed this visit

Physical Exam

General:
well developed, well nourished, in no acute distress.
Lungs:
clear bilaterally to auscultation.
Heart:
normal S1, S2 without murmurs, rubs, gallops, or clicks.
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.


Impression & Recommendations:

Problem # 1: DEPRESSION, CHRONIC (ICD-311)
Will continue weaning. So will decrease Paxil to 10mg once daily x 4 days (while taking Lexapro 10mg ) then stop Paxil and increase Lexapro to 20mg once daily
His updated medication list for this problem includes:
Lexapro 20 Mg Tabs (Escitalopram oxalate) ..... Take one tab by mouth once daily
Paroxetine Hcl 20 Mg Tabs (Paroxetine hcl) ..... Take one tab by mouth once daily

Orders:
Exp. Prob. Focus SF (CPT-99213)


Medications Added to Medication List This Visit:
1) Lexapro 20 Mg Tabs (Escitalopram oxalate) .... Take one tab by mouth once daily

Complete Medication List:
1) Lexapro 20 Mg Tabs (Escitalopram oxalate) .... Take one tab by mouth once daily
2) Paroxetine Hcl 20 Mg Tabs (Paroxetine hcl) .... Take one tab by mouth once daily

Prescriptions:
LEXAPRO 20 MG TABS (ESCITALOPRAM OXALATE) Take one tab by mouth once daily #30[tablet] x 1
Handout requested.

Patient Instructions:
1) Continue weaning off of Paxil. Decrease Paxil to 10mg once daily for 4 days (while taking Lexapro 10mg once daily) then stop Paxil and increase Lexapro to 20mg once daily.
2) Please schedule a follow-up appointment in 1 month.



Electronically signed by _xxxxxxxxxxxxxxxx__

 

[rda23@aol.com]

MDM support

I think you've got enough there for the MDM to justify 99213. You've got a chronic condition that's not really making too much progress, and you're dealing with prescription drug management, which takes your Risk level to Moderate.

 

[MikeEnos]

You easily have enough there for a 99213. Think about the requirements for a 99212:

-Problem Focused History (1 HPI element, No ROS, No PFSH)
- Problem Focused Exam (1 organ system/body area)
-Straightforward MDM

In my judgement, this note easily satisfies the requirements for a 99213:
- Expanded Problem Focused History (1 HPI element, 1 ROS, 0 PFSH)
- Expanded Problem Focused Exam (2 organ systems or body areas)
- Low complexity MDM

And remember you only need to meet or exceed 2 out of 3 of those key components.