In my years of coding for rheumatology, I am often asked this type of question: “I have a patient who recently came in for a visit. She had two or three diagnoses, was placed on three or four different medications, and we ran one or two labs on her. Does this qualify for a level-four visit?”
The answer—as is usually the case in coding—is not always an easy one. Medical decision making is only one component of the evaluation and management levels. Although it is true that the medical decision drives your level of coding, it is not the only element of the visit.
Deciding what the level of medical decision making should be can be a confusing process. The important thing to remember with medical decision making is, when medical records are being audited, the medical decision-making section is based on a point system, and your knowledge of this point system will make or break you when submitting claims.
Let’s look at a specific scenario to test your knowledge of the point system. This month, we’ll start right with the diagnosis.
Diagnosis: Rheumatoid arthritis with active disease, gastrointestinal reflux disease (GERD).
Assessment Plan: The review of labs, done six weeks prior, showed mild anemia and elevated erythrocyte sedimentation rate and C-reactive protein. Other labs were normal. Therapeutic options were discussed with the patient and the decision was made to add tumor necrosis factor (TNF)–alpha inhibitor. Actions, side effects, and administration of TNF-alpha inhibitors were reviewed with patient. Laboratory studies were ordered along with a chest X-ray. A purified protein derivative (PPD) test was placed on patient’s right forearm, and the patient was continued on celecoxib, methotrexate, folic acid, and lansoprazole. The patient was also given a prescription for occupational therapy evaluation and treatment, including finger splints. The patient was scheduled to return to office in three days to have the PPD read and for a patient-education visit with a registered nurse to learn self-administration of TNF-alpha injections.
How would you code this?