MarthaS_39597
New member
Good afternoon and thank you for the add! I was recently referred to this forum and hope that I could get some assistance from experienced coders on 2 enc that I am reviewing under the new 2021 guidelines. I am so used to the points calculation that I am stumped on one area of the MDM- the number of problems addressed in the encounter. I have the AMA table and I see the different examples of problems and what counts to low, moderate, and high. But I am really struggling with trying to determine where the dx codes for my enc fit on this table. I work with pain mgmt and I review the notes for leveling, the provider chooses the dx codes in the EMR that pertain to the encounter. 1)My first enc is an established patient being treated for his low back pain. The hx listed notates the patient has been experiencing back pain for several years and his pain is being managed by my provider. No new pain is addressed, the pain is localized in low back, pt has 3/10 pain level with meds and meds manage his pain well and he is able to perform ADL. An appropriate exam was performed on the low back area. The dx listed by the provider are M46.1 (sacroilitis) and M47.816 (Spondylosis Lumbar Region) both are notated as stable. The provider reviewed the PDMP report and has decided to refill the pts hydrocodone. Would this be considered a 99213 or 99214? There are 2 dx listed, they are not considered self limited problems, or new, or acute. I am unclear if I should consider this as 1 chronic stable illness, since he is managing the low back or since there are 2 dx codes that pertain to the back if I should consider them as 2 stable chronic. According to the AMA guidelines chronic is defined as a problem with expected duration of 1 year or until death....the provider has been treating the patient for several years for the low back.
2) My second enc is also an established patient being treated for neck and low back. The hx listed notates the pain has been present since 2012, there is no new pain, and the patient experiences radiating pain to the arms and to the legs. The meds manage the pain and the patient has 2/10 pain level with these meds, without the meds pain is at 8/10. An exam was performed on the neck and low back. The provider is treating the patient with meds and the dx listed are M54.12 (cv radiculopathy) and M54.16 (lumbar radiculopathy)..the patients pain is stable with the current medication and the provider is going to refill the oxycodone. He is also ordering a UDT for the patient to have at an outside lab. I am leaning to 99214 on this encounter because the provider is treating 2 different areas the neck and the low back...Is this correct or am I totally losing it...LOL
If I could get some assistance with this I would be so grateful …Some of the forums I have checked are giving me mixed info...I am getting several people saying to code level 3 and some say level 4. If this was 2020 and I was simply counting the # of dx under the point system I would have given a total of 2 points for stable dx on both pts, minimal on the data for both pts, and moderate on the risk for both enc since RX refills were given, with an overall MDM of LOW for 2020. But under the new table it seems these enc would possibly get an overall of MODERATE on MDM
2) My second enc is also an established patient being treated for neck and low back. The hx listed notates the pain has been present since 2012, there is no new pain, and the patient experiences radiating pain to the arms and to the legs. The meds manage the pain and the patient has 2/10 pain level with these meds, without the meds pain is at 8/10. An exam was performed on the neck and low back. The provider is treating the patient with meds and the dx listed are M54.12 (cv radiculopathy) and M54.16 (lumbar radiculopathy)..the patients pain is stable with the current medication and the provider is going to refill the oxycodone. He is also ordering a UDT for the patient to have at an outside lab. I am leaning to 99214 on this encounter because the provider is treating 2 different areas the neck and the low back...Is this correct or am I totally losing it...LOL
If I could get some assistance with this I would be so grateful …Some of the forums I have checked are giving me mixed info...I am getting several people saying to code level 3 and some say level 4. If this was 2020 and I was simply counting the # of dx under the point system I would have given a total of 2 points for stable dx on both pts, minimal on the data for both pts, and moderate on the risk for both enc since RX refills were given, with an overall MDM of LOW for 2020. But under the new table it seems these enc would possibly get an overall of MODERATE on MDM
