Newbie...can someone please verify my MDM to appropriately bill 99204 for all new patients?

[Ducttape]

maybe.

but if, as per his statement, "continue gaba or rx nsaid prn", upcoding based on this seems an overreach.

2 stable diagnoses gets you to level 4 on problems, but by itself without complexity and minimal risk, only gets you to level 2.

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[deleted875186]

maybe.

but if, as per his statement, "continue gaba or rx nsaid prn", upcoding based on this seems an overreach.

2 stable diagnoses gets you to level 4 on problems, but by itself without complexity and minimal risk, only gets you to level 2.

Sure, the e and m guidelines are subjective. I can reasonably defend billing a level
4 based on what was written in the note. So long as the detail is in the note, I think it’s reasonable. But could definitely argue a level 3.

 

[cameroncarter]

Hi all, am I counting the number of MDM "problems" in my encounters correctly?

Patient 1: lumbar radiculopathy and knee osteoarthritis: 2 chronic problems
Patient 2: lumbar radicuolopathy and obesity (counseling provided/referred to obesity clinic): 2 chronic problems
Patient 3: lumbar spondylosis and sacroiliitis: 1 chronic problem
Patient 4: lumbar spondylosis and depression/anxiety (no meds given, but counseled on importance of managing depression/anxiety in treating chronic pain): 1 or 2 chronic problems?

 

[RoloTomassi]

You can make every patient as granular as you want and really say almost anything is uncontrolled/with progression/acute exacerbation. For all the above it's easy to rack up as high as you want (more than you have). The key is documenting each item with that language.

 

[Ducttape]

yes. 2 problems.

dont forget not only treatment plan but document ICD-10 code for each of those problems.
for example, M54.16 and M53.3, or M47.816 and F06.31