Friday, 27 December 2013

The only difference between the history requirements for a 99212 and a 99213 is the review of systems.(CPT 99212, 99213 visit history)

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver). The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider. 

Risk. The risk associated with an E/M visit is based on the chance that significant complications,

morbidity or mortality occur during the current encounter/procedure or between the present encounter and the next one. The guidelines characterize these in the context of the presenting problems, diagnostic procedures and management options. The highest level of risk in any one of the three categories determines the overall risk.

The risk associated with a level-II visit is considered minimal. Examples include a presenting

problem that is self-limited or minor; diagnostic procedures such as labs with venous puncture, chest X-rays, ECGs, EEGs, urinalysis, ultrasound and KOH preparation; or management options such as prescribing rest, gargles, elastic bandages and superficial dressings. Level-III visits are considered to have a low level of risk. Patient encounters that involve two or more self-limited problems, one stable

chronic illness or an acute uncomplicated illness would qualify. Diagnostic procedures with low risk include physiologic tests not under stress, non-cardiovascular imaging studies with contrast, perficial needle biopsies, labs requiring arterial puncture and skin biopsies. Lowrisk management options include prescribing over-the-counter drugs, minor surgery with no identified risk factors, physical therapy, occupational therapy and IV fluids without additives.

Time-based billing

Another option for coding level-II and level- III encounters is to use time as your guide. According to CPT, a typical level-II visit lasts 10 minutes, while a typical level-III visit lasts 15 minutes. If counseling or coordination of care account for more than 50 percent of the visit, then you can select your E/M code based on the length of the visit. In general, the time spent face-to-face with the patient (and the time spent in counseling) should meet or exceed the listed typical visit times. Remember,

the coders who audit your charts do so by counting required components as well as noting recorded visit times. If you decide to use time-based billing, make sure to include in your note that at least half of the face-to-face time was spent counseling or coordinating care (e.g., “total visit time was 15 minutes, half of which was counseling”). Your documentation should also describe the nature of the counseling or care coordination.

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