Wiki What level would you bill?

[Colliemom]

A physician and I are disagreeing on the level to bill for this visit.

So this is an established patient visit

There is a detailed hx and a detailed exam. The area of disagreement is the MDM. The patient has only the one established problem, that is not worsening. There is no data/tests to review. The plan of care is "lifting capacity will be raised to 30 pounds. He should follow up in 3 months time. In the interim he is to continue strengthening."

So to me, this is straightfoward MDM.
Diagnoses: One established problem, not worsening = straightfoward
Amount & complexity of data is minimal/none = straightfoward
Risk - presenting problem could be low, but diagnostic procedures ordered and management options would only be minimal = straightfoward

The physician feels that this visit is definitely not a 99212. He thinks it should be a 99213, even though I explained that the MDM is the overarching criteria in choosing your code level. He told me, these problems have orthopaedic levels of complexity that are not fully appreciated by one without an orthopedic background.

I admit, I am new to ortho coding, so I am looking for your opinions. What would you code this visit as?

 

[Colliemom]

bump until someone responds

 

[cgaston]

For an established patient you only need to hit 2 out of 3 so you could technically bill a 99214 because you have detailed history and detailed exam.

I personally don't like ignoring the MDM but I am just putting it out there....

 

[thomas7331]

Agree, per coding guidelines, only two of the three are required. I would not assign a level based on MDM alone. Medical necessity is the overarching criteria, not MDM - these two are not the same thing.

If there is a detailed history and exam, then a 99213 is certainly supported if that is what the provider feels is appropriate for the visit. The provider has effectively already down-coded the service from a 99214 to 99213 based on his assessment of the appropriate level for the patient's problem, so I would not down-code it again. The provider is correct that the problem may require the level of history and exam that is higher than the MDM and should be reimbursed for that work if it is medically necessary. Sometimes it takes a more extensive history and exam to reach a conclusion that the patient is stable or only needs minor treatment and the provider should not lose out on the work of the history and exam simply due to the outcome that is reflected in the MDM.