Wiki Poison Ivy/Poison Oak

[Brenda1973]

Diagnosis: Contact dermatitis and eczema due to plant.
Can someone help me with the MDM level of this. I'm trying to tally all 3 elements of MDM.
Where does this fall on the MDM table under the first column "Number and complexity of problems addressed?" Is poison ivy considered "minimal or low?"
It's a common diagnosis and all my providers are coding it straightforward MDM 99202,99212.
I believe it should be a low MDM 99203,99213 as medications and creams are being prescribed.
My issue is not knowing how to rank this under the first column of MDM "number and complexity of problems addressed. Again is it "straight forward" as a rash or is it "low" as an acute illness or injury?

 

[xXxPARAGONxXx]

Poison ivy dermatitis rashes are self-limited.

Source: https://www.aocd.org/page/PoisonIvyDermatiti

Poison ivy dermatitis is an acute self-limiting problem of two or three weeks' duration that can cause significant discomfort.

Source: https://pubmed.ncbi.nlm.nih.gov/6225038/

This rash is usually self-limiting and resolves one to two weeks after exposure.

Source: https://www.aafp.org/pubs/afp/issues/2000/0601/p3408.html

“Number and Complexity of Problems Addressed at the Encounter”
Minimal: 1 self-limited or minor problem

This makes it straightforward (99202 for new patient office visit; 99212 for established office visit).

 

[Brenda1973]

Source: https://www.aocd.org/page/PoisonIvyDermatiti


Source: https://pubmed.ncbi.nlm.nih.gov/6225038/


Source: https://www.aafp.org/pubs/afp/issues/2000/0601/p3408.html

“Number and Complexity of Problems Addressed at the Encounter”
Minimal: 1 self-limited or minor problem

This makes it straightforward (99202 for new patient office visit; 99212 for established office visit).

Thank you so much for clarifying! I appreciate that!
I am having the same issue with "sinusitis/ acute bacterial sinusitis" If you have any advice on that as far as is it considered "self limited or acute, uncomplicated illness?"

 

[xXxPARAGONxXx]

Thank you so much for clarifying! I appreciate that!
I am having the same issue with "sinusitis/ acute bacterial sinusitis" If you have any advice on that as far as is it considered "self limited or acute, uncomplicated illness?"

It is typically self-limited, but it could become more complex. That would depend on the history elicited by the provider (to determine the progression of the illness) and the physical examination.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7122468/

Acute bacterial rhinosinusitis is generally a self-limited disease and can resolve on its own without antibiotics.

Furthermore, ibid.,

It is also important to understand that establishing a diagnosis of ABRS does not necessitate the prescribing of antibiotics, unless the ABRS patient presents with severe or worsening symptoms or an ABRS complication.

ABRS which does not require antibiotics means no prescription management, and a self-limited problem, which would be coded as straightforward (99202, 99212).

On the other hand, if the ABRS does not resolve on its own, it then becomes an “acute, uncomplicated illness or injury”. Per 2024 CPT, p. 11,

A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.

Prescription management, and an acute, uncomplicated illness, would be coded as low (99203, 99213).

By the way, the timeframe whereby ABRS would be expected to resolve on its own is approximately 2 weeks.

Ibid.,

Systematic reviews and meta-analyses have found that the majority of patients with ABRS will resolve their symptoms without antibiotic therapy within 2 weeks

 

[Brenda1973]

It is typically self-limited, but it could become more complex. That would depend on the history elicited by the provider (to determine the progression of the illness) and the physical examination.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7122468/


Furthermore, ibid.,


ABRS which does not require antibiotics means no prescription management, and a self-limited problem, which would be coded as straightforward (99202, 99212).

On the other hand, if the ABRS does not resolve on its own, it then becomes an “acute, uncomplicated illness or injury”. Per 2024 CPT, p. 11,



Prescription management, and an acute, uncomplicated illness, would be coded as low (99203, 99213).

By the way, the timeframe whereby ABRS would be expected to resolve on its own is approximately 2 weeks.

Ibid.,

Great information! Thank you again!