Wiki What level would you give this?

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RebeccaMoney

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My provider says 99214. MRI was reviewed and PT ordered. I'm thinking 99213. Clinic note is attached for your review. Please give me your reasoning on the level you choose.
Thank you,
 

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Yes, I would agree with you. Acute injury problem (sprain) - low, minimal data, and low risk of physical therapy and non-steroidal anti-inflammatory equals 99213 e/m level.
 
I also agree with 99213.
Problem - low for acute uncomplicated. If you wanted to stretch, MAYBE you could say acute complicated due to the ganglion cysts, but the provider specifically states the sprain is unrelated, so I would say low.
Data - none or minimal - possibly reviewed report of 1 test. It seems to indicate this practice ordered the MRI at prior visit, so review is included. You would potentially get to moderate if the physician performed independent interpretation of the MRI images, which is not documented here.
Risk - low for PT and OTC meds. You would only get moderate if there was prescription management, or surgery decision, or treatment limited by SDOH, or other treatment resulting in a higher risk than you have documented here.
So, even if you stretch the problem to moderate, you clearly don't have moderate for either data or risk.
I just don't see how to get to 99214 with this documentation.
 
I also agree with 99213. Acute uncomplicated injury, low risk treatment.

I don't see any way to justify a 99214 based on MDM. If the provider's thinking is based on time, they should have documented time.
 
csperoni said:
I just don't see how to get to 99214 with this documentation.
Click to expand...
Indeed. Maybe there's something the provider considered, but did not document related to the MDM that could push it to a higher level such as the suggestions that Christine stated. You could try inquiring with the provider regarding why s/he feels it's a level 4 instead of a level 3 when the documentation doesn't show a higher level.
 
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