Wiki Rheumatology - R/A

[CBC]

I'm seeking advice on stable RA on High risk therapy (Methotrexate & Enbrel). Physician states level 4. His HPI is 1 stable chronic condition. His exam meets detailed level 4. The MDM is still 1 chronic stable condition even though on High risk therapy? He also reviewed most recent labs - CBC & LFT's (unremarkable). Due to the fact that everythings is stable, wouldn't we fall into a PF 99212 area? I understand we can reach a 4 if we had additional problems being treated. Any advise appreciated.

 

[sullivak]

I'm no RA expert, but the fact that this condition is being treated with such high risk therapy would indicate to me that it is not so stable a problem. At least a two pointer for DMO. Of course, risk would be high. That would make it at least a low MDM visit. Based on this, I would give it a 99213.