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When I see a patient with multiple problems (for example, MDD, GAD, PTSD, and ADHD), and I am treating them with medications, how should I code the encounter when everything is stable?
It's pretty clear to me that if something is worsening or not improving, and I'm needing to adjust meds, 99214 is most appropriate (unless it's really severe or complicated, warranting a 99215). But what if the patient comes in and says everything is finally doing well, and no changes are needed? I can quickly gather history on each of their problems, do a detailed exam, and continue treatment with the same medications, but the amount of work is much easier and may only take 10 minutes from start to finish. Should this get a 99214 as well, or would 99213 be more appropriate?
As far as the complexity goes, it seems that 99214 is justified; after all, this does require more work than just a single stable problem, like a follow up for routine ADHD or mild depression. But because everything is doing well and I don't have to work as hard, the effort I put into it feels like a 99213.
If I refer to this coding guide, I can easily get a detailed history with 3+ chronic conditions, perform a detailed MSE, and have moderate medical decision making with 3+ problem points for established problems and prescription drug management, which would be sufficient for coding 99214. I'm just wondering whether the severity of each problem is a factor in deciding which code to use. How do you code encounters like this?
It's pretty clear to me that if something is worsening or not improving, and I'm needing to adjust meds, 99214 is most appropriate (unless it's really severe or complicated, warranting a 99215). But what if the patient comes in and says everything is finally doing well, and no changes are needed? I can quickly gather history on each of their problems, do a detailed exam, and continue treatment with the same medications, but the amount of work is much easier and may only take 10 minutes from start to finish. Should this get a 99214 as well, or would 99213 be more appropriate?
As far as the complexity goes, it seems that 99214 is justified; after all, this does require more work than just a single stable problem, like a follow up for routine ADHD or mild depression. But because everything is doing well and I don't have to work as hard, the effort I put into it feels like a 99213.
If I refer to this coding guide, I can easily get a detailed history with 3+ chronic conditions, perform a detailed MSE, and have moderate medical decision making with 3+ problem points for established problems and prescription drug management, which would be sufficient for coding 99214. I'm just wondering whether the severity of each problem is a factor in deciding which code to use. How do you code encounters like this?
