ICD-10: M17.12, E66.01, Z68.41
CPT: 99213
ICD-10: M1a.0710, M05.79
History—The history of present illness was extended. The review of systems was extended, and two past family social history elements were documented. This makes the history level detailed.
Examination—Five systems were examined. This makes the exam level detailed.
Medical decision making—There were two stable or improved established problems, which makes this a limited visit. The data reviewed included an X-ray and some labs, and some lab tests were ordered, which makes this limited. The level of risk was moderate for prescription drug management. Although the CPT coding manual states only two of the three—history, examination and medical decision making—are needed to meet level 4 for an outpatient visit, the presenting problem drives the level of the visit. This means the level of the history, examination or medical decision making must meet the medical necessity of performing the service. In this scenario, the two presenting problems were stable and/or improving; this does not meet the medical necessity of a level 4, established patient visit.
Note: The scenario states the rheumatologist spent time with the patient face to face, going over diet and an exercise program and giving instructions for what to do in the event of an acute flare. The CPT coding manual states that a typical established patient level 4 visit should take 25 minutes, and if more than 50% of the visit was spent face to face and more than 50% was spent counseling and/or coordinating care at this visit, and there was documentation of what was discussed, then the visit would meet the medical necessity of a level 4 visit.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.
