How do you determine the level of the History portion? Example – if patient has brief HPI, detailed ROS and no PFSH?
How do you determine the level of Medical Decision Making?
Thanks.
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Tag Archives: Leveling
E/M Leveling New patient
Evening,
Need anyone’s insight regarding risk. Just want to double check with everyone to make sure I’m handling the following example correctly. For this example I would code as a 99203 due to the decadron(3) given in office and also the prescription for ofloxacin(3) and history(3) exam(3). Also this example is similar to another question I have currently on the forum, meant to add this question with the original.
CC: Ear pain for 3 days
27 year old male, new patient presents with earache ongoing for 3 days. Ear does have slight drainage and tender to touch. Pt denies headache, nausea, cough, discomfort of eyes along with no discomfort of throat.
Medical History: Knee surgery 2007
Family: Mother heart disease, hypertension
Social: Occasional alcohol
Constitutional: 100 body temp
Pt looks state age, well groomed
Eyes: clear, bright,
ENMT: ear is tender, some drainage, mildly swollen, red.
Respiratory: breathing is well, no crackles, etc…
Integumentary: skin is warm to touch
Due to the drainage, tenderness and slight swelling of the ear did give a dose of decadron in office. Will prescribe ofloxacin. Go to emergency department if symptoms worsen
E/M Leveling Question 3
Good Evening,
Need insight regarding the mdm. The question I have is regarding how I’m coding the claim when the dr has prescribed a prescription along with giving a strep test. The code I see with the following example is a 99202 with the drug prescription(3) strep test(1) problems(2) history(3) Exam(3). The insight I was told was that due to the dr prescribing the drug and along with doing a strep test I would code a 99203 otherwise without the strep test it would be considered straightforward 99202. Example:
CC: Ear pain and sore throat for 3 days
27 year old male, new patient presents with earache and sore throat ongoing for 3 days. Ear does have slight drainage and tender to touch. Patient states throat a little scratchy and sore hard to swallow. Pt denies headache, nausea, cough, discomfort of eyes along with no sob, chest pain.
Medical History: Knee surgery 2007
Family: Mother heart disease, hypertension
Social: Occasional alcohol
Constitutional: 100 body temp
Pt looks state age, well groomed
Eyes: clear, bright,
ENMT: ear is tender, some drainage, mildly swollen, red. Throat feels to be a little warm
Respiratory: breathing is well, no crackles, etc…
Integumentary: skin is warm to touch
Due to the drainage, tenderness and slight swelling of the ear will prescribe ofloxacin. For the sore throat performed strep test which was negative. Advise pt warm salt water gargles and otc anti-inflammatory throat spray and lozenges. Go to emergency department if symptoms worsen
Straightforward E/M Leveling lookup table
If anyone’s interested, I’ve created a simplified lookup table that let’s you know exactly which CPT code to use for any E/M subcategory whose codes are based on History, Exam and Medical Decision Making. If you’re taking the CPT exam, you can transcribe the table into your book, and I’m sure you’ll find it useful.
The table can be found here: https://docs.google.com/spreadsheets…it?usp=sharing.
An explanatory video is here: https://youtu.be/cCj0yA6AAbA.
Please let me know if you find it helpful.
E/M leveling
Can someone please help me clear this up? For a new patient, if the provider only addresses one condition in the HPI, can this only qualify as a 99202? (Time is not documented by the way).
I have an E/M tool from Optum and it says in order to qualify for a 99203, the provider needs to document 4+ elements OR status of 3+ chronic conditions. But when I am looking for other E/M leveling tools, I see some that say "3 chronic conditions OR 4+ elements". If the provider documents 4+ elements of only one condition, can that still qualify as a 99203? I hope this makes sense.
Differences of E/M Leveling in Physician-based and Hospital-based Clinics
Hospital-based clinics have a relationship with their hospital, although it’s not usually located within the walls of the hospital. The relationship allows the hospital and the clinic to share costs and revenue. Whereas a physician-based clinic is a private physician-owned clinic where all the services and expenses are bundled into a single charge. Clearing Up Confusion In […]
AAPC Knowledge Center
ED E&M Leveling: 99283 vs 99284?
Hi,
I would like to have your insights about this scenario:
DX: headache
history: comprehensive
exam: comprehensive
mdm: moderate
-visual acuity done, CT scan was done and Rx given no other complaints.
-no neuro checks/exam ordered or performed.
-discharged
Will this be a level 4 because of the CT scan? or just a level 3 because headache is the only presenting prob and dx?
Thanks.
ED E&M Leveling: 99283 vs 99284?
Hi,
I would like to have your insights about this scenario:
DX: headache
history: comprehensive
exam: comprehensive
mdm: moderate
-visual acuity done, CT scan was done and Rx given no other complaints.
-no neuro checks/exam ordered or performed.
-discharged
Will this be a level 4 because of the CT scan? or just a level 3 because headache is the only presenting prob and dx?
Thanks.
Inpatient E/M Leveling Tools Needed
Does anyone know of any tools to use to determine Inpatient E/M levels? I work for Gynonc Surgeons and I am new to Inpatient E/M leveling. I have been told that the requirements for leveling office visits are different than inpatient and using the auditing tool for office E/M is not adequate for inpatient visit. Any feedback is greatly appreciated. 