In Part 1 of this series, we covered the vital role of medical decision making in determining the final level to bill for a patient encounter. Medical decision making is the key component in coding because it reflects the intensity of the provider’s cognitive labor. This implies that there’s an unseen component involved in the…
I was driving to work one morning when I stopped behind a truck at a red light. The driver had placed several flashy stickers on the bumper and back doors. But what I was drawn to was a more commonplace sign: “How’s my driving? Call this number to give feedback.” It’s routine to find a…
The Medical Decision Making (MDM) of an evaluation and management (E/M) visit is one of the three components of determining the level of a patient’s visit. But the MDM can sometimes be the most difficult component, as this is where the provider’s thought process is quantified in deciding the correct level of E/M service. In the…
A 50-year-old male patient returns to the office for a follow-up visit for a diagnosis of generalized primary osteoarthritis of multiple sites. The patient tells the medical assistant that he is experiencing sharp throbbing pain in his left hip and right and left knees. He states the pain level is 6 out of 10 and…
Take the challenge. Answers: B: No—Only the treating physician can take the HPI. The medical assistant is allowed to take the review of systems. If the documentation indicates the treating physician did not take the HPI, the insurance can deny the claim as not medically necessary. B: No—If the high-risk medication is not assessed and…
Take the challenge. CPT: 99213 Diagnosis Codes: M05.79, M17.12, Z79.1, Z79.899 Rationale to code this encounter as 99213: History—The history of present illness was extended. The review of systems was comprehensive, and two of the three past, family and social history were documented. This makes the history level comprehensive. Eight systems were examined. This makes…
Level 3 Established Patient E&M Visit A 43-year-old patient is seen in the office for a follow-up visit of her RF-positive rheumatoid arthritis and primary osteoarthritis of the left knee. The patient is on sulindac, methotrexate and folic acid. At her last visit, the patient’s methotrexate dose was increased, which has greatly reduced her pain….
Tips on defining new and established patients; determining an appeal approach
Does your staff know what is involved in taking a complete history from a patient?
November’s Coding Challenge