e + m

[mille125]

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Yes, you don't need to include any of that.

Here's an example of a 99204 I wrote today. Everything in the MDM after the first 3 lines is a macro I use for all MBBs. Note took me literally 2 minutes to write.


HPI
HPI: New patient presenting for evaluation of chronic low back pain, worsening since approximately September/October of last year. Unable to take NSAIDs due to prior gastric bypass. Over the past 2-3 weeks, pain has worsened. Reports similar pain in the cervical region, with symptoms extending up and down the neck.

This note was completed with the assistance of voice recognition software. Please excuse any typos or misspellings. Please contact the office with any concerns.
ROS
ROS as noted in the HPI
Physical Exam
Facet loading POSITIVE BILATERALLY in the lumbar region.
Paraspinal TTP noted in the lumbar region.
Procedure Documentation
Test Interpretation:
X-rays of lumbar spine (today): Mild facet arthropathy at L4-5 and L5-S1, degenerative disc disease at L5-S1
Assessment / Plan

1. Spondylosis of lumbar spine​

Chronic lumbar spondylosis/facet arthropathy with refractory pain despite conservative management, limited to acetaminophen due to history of gastric bypass. Examination and imaging confirm facet-mediated pain. Will proceed with bilateral L4-S1 medial branch blocks (MBB) to confirm diagnosis, with plan for radiofrequency ablation (RFA) at same levels if positive response. Cervical pain likely facet-mediated as well; will address at future visit after lumbar intervention.​

Will plan on diagnostic MBB of BILATERAL L4-5, L5-S1 at next visit with ultimate plan for RFA of the same levels.​

Justification for interventional procedure:​

1. Patient has moderate to severe pain 9/10 which interferes with ADLs​

2. Pain has been present for >3 months and has failed to respond to conservative measures including OTC analgesics, behavior modification and home exercises​

3. Patient has no untreated radicular symptoms​

4. No alternative pain generator suspected beyond facetogenic pain at this time.​

​

Thanks for example.

This is absolutely a level 4 99204

Complexity of Problems....You can argue it is exacerbation of a chronic condition (low back pain) or 2 stable conditions (back and neck pain). Either way you get a check here.

Complexity of Data...You review what appears to be an outside film that the patient brought in. If that is correct you can get a check here. You also get a check if you ordered the film but you dont get a check if you review it at the next visit.

That alone is enough to bill 99204 but it appears that you are also discussing and scheduling a minor procedure which gives you a check for risk of complications.

Many wont do this but you have 3 of 3 categories checked so you actually have a 99205 here.

 

[BoardingDoc]

Thanks for example.

This is absolutely a level 4 99204

Complexity of Problems....You can argue it is exacerbation of a chronic condition (low back pain) or 2 stable conditions (back and neck pain). Either way you get a check here.

Complexity of Data...You review what appears to be an outside film that the patient brought in. If that is correct you can get a check here. You also get a check if you ordered the film but you dont get a check if you review it at the next visit.

That alone is enough to bill 99204 but it appears that you are also discussing and scheduling a minor procedure which gives you a check for risk of complications.

Many wont do this but you have 3 of 3 categories checked so you actually have a 99205 here.

So this doesn't actually meet criteria for 99205.
Minor procedure w/ risks only gets a lvl 4 in column 3.
Chronic issue w/ severe exacerbation would count as lvl 5 in column 1

Column 2 though. I get halfway with imaging interpretation, but I would need to either also order 3 tests, or a test and review 2 outside records, or similar.

3 columns meeting lvl 4 != lvl 5

2+ columns meeting lvl 5 = lvl 5

This chart is a lvl 4.

 

[clubdeac]

So this doesn't actually meet criteria for 99205.
Minor procedure w/ risks only gets a lvl 4 in column 3.
Chronic issue w/ severe exacerbation would count as lvl 5 in column 1

Column 2 though. I get halfway with imaging interpretation, but I would need to either also order 3 tests, or a test and review 2 outside records, or similar.

3 columns meeting lvl 4 != lvl 5

2+ columns meeting lvl 5 = lvl 5

This chart is a lvl 4.

This is spot on, Mille confused

 

[mille125]

This is spot on, Mille confused

Yes...you are correct.

I misspoke

That is what happens when you are trying to do 3 things at once.

 

[FSQT]

For patients coming in for one single issue (ie LBP), is it kosher to use G89.29 "chronic pain" for the second stable chronic diagnosis to meet MDM level 4 for "number and complexity of problems addressed?"

I do talk to all of my patients about the role of sleep, psychosocial stressors, and exercise in chronic pain, and document.

 

[Ducttape]

I think it is impt to understand this so let my reiterate.

There are three general categories. You need to have two of these three groups to bill level 4

Complexity of problems
Complexity of data
Risk of complications

Complexity of problems level 4 ...you need 1 chronic problem with exacerbation OR 2 stable chronic problems (that you are treating) OR one acute problem

Complexity of data level 4 ......you need 1 Order a new test OR 2 Review a test someone else ordered OR 3 Discuss a test with another doctor

Risk of problems level 4 .....you need 1 Prescribe a medication OR 2 Discuss a minor or elective surgery

per my understanding and what billing has told me correct

Of note reviewing a test that you previously ordered does not count in Complexity of Data


So as an example

A patient that you see for neck and low back pain that you write a prescription for is level 4
Same patient that you did not write a prescription for but you order a new MRI is also a level 4



I believe this is how it is done but if I missed something please let me know.

the order only counts for 1 point in the data section. using the calculator, i still get a 3.

the preponderance of strength is on medical decision making.

ordering the MRI doesnt get you to 4 if your MDM is still low.

tho i believe if you order a CT myelogram, then you can get to a 4, because the CT myelogram also may fall in the "other moderate risk testing or treatment".

if you give a script for flexeril (dont do it or you may get dinged in this new ambulatory specialty model) then you get a 4. or give a dose of toradol in the office.


also, when applicable, use social determinants of health to get to a level 4. it makes the complexity Moderate.

I think I know your answer but If our patients fill out a paper h+P which is (eventually) scanned in and includes meds and PMH, then when I do my dictated (dragon note) can I not include irrelevant meds and irrelevant PMH/PSH?

sign and scan. then have prewritten in your note "scanned documents reviewed and discussed."

Yes, you don't need to include any of that.

Here's an example of a 99204 I wrote today. Everything in the MDM after the first 3 lines is a macro I use for all MBBs. Note took me literally 2 minutes to write.

​

im not sure that qualifies as moderate decision making (to get to 99204) because it would be hard pressed to justify that the MBB is a "minor surgery with identified patient or procedure risk factors".

 

[buddababa]

im not sure that qualifies as moderate decision making (to get to 99204) because it would be hard pressed to justify that the MBB is a "minor surgery with identified patient or procedure risk factors".

i think all our neuraxial procedures qualify under that. you can argue against joint injections, but even if you discuss back surgery and risks/details/benefits etc, thats level 4, you could argue its a level 5 (what surgeon said) - thats what he bills when he sets patients up for surgery

 

[bedrock]

i think all our neuraxial procedures qualify under that. you can argue against joint injections, but even if you discuss back surgery and risks/details/benefits etc, thats level 4, you could argue its a level 5 (what surgeon said) - thats what he bills when he sets patients up for surgery

Seems like duct is always downplaying what we do. Neuroaxial injections are NOT the same complexity as peripheral joint. Most of our notes should be level 4.

I agree with SSdoc that if we do something it’s a 4, if not it’s a 3.

 

[bedrock]

Yes, you don't need to include any of that.

Here's an example of a 99204 I wrote today. Everything in the MDM after the first 3 lines is a macro I use for all MBBs. Note took me literally 2 minutes to write.


HPI
HPI: New patient presenting for evaluation of chronic low back pain, worsening since approximately September/October of last year. Unable to take NSAIDs due to prior gastric bypass. Over the past 2-3 weeks, pain has worsened. Reports similar pain in the cervical region, with symptoms extending up and down the neck.

This note was completed with the assistance of voice recognition software. Please excuse any typos or misspellings. Please contact the office with any concerns.
ROS
ROS as noted in the HPI
Physical Exam
Facet loading POSITIVE BILATERALLY in the lumbar region.
Paraspinal TTP noted in the lumbar region.
Procedure Documentation
Test Interpretation:
X-rays of lumbar spine (today): Mild facet arthropathy at L4-5 and L5-S1, degenerative disc disease at L5-S1
Assessment / Plan

1. Spondylosis of lumbar spine​

Chronic lumbar spondylosis/facet arthropathy with refractory pain despite conservative management, limited to acetaminophen due to history of gastric bypass. Examination and imaging confirm facet-mediated pain. Will proceed with bilateral L4-S1 medial branch blocks (MBB) to confirm diagnosis, with plan for radiofrequency ablation (RFA) at same levels if positive response. Cervical pain likely facet-mediated as well; will address at future visit after lumbar intervention.​

Will plan on diagnostic MBB of BILATERAL L4-5, L5-S1 at next visit with ultimate plan for RFA of the same levels.​

Justification for interventional procedure:​

1. Patient has moderate to severe pain 9/10 which interferes with ADLs​

2. Pain has been present for >3 months and has failed to respond to conservative measures including OTC analgesics, behavior modification and home exercises​

3. Patient has no untreated radicular symptoms​

4. No alternative pain generator suspected beyond facetogenic pain at this time.​

​

Thanks. Does your your lumbar MBB template always include “cervical pain likely facet mediated as well”?

 

[Ducttape]

so an epidural or an MBB has the same level of medical decision making and the same level of risk as a thoracotomy or lumbar diskectomy or TAH or subdural evacuation...

i personally find it hard to believe that what we do - elective procedures with extraordinarily low risk - is at that high a level.



the wording is not "discuss". it is "decision to perform procedure", meaning to me that one has to do all the work to get procedure approved including but not limited to discussion with the patient.

 

[bedrock]

so an epidural or an MBB has the same level of medical decision making and the same level of risk as a thoracotomy or lumbar diskectomy or TAH or subdural evacuation...

i personally find it hard to believe that what we do - elective procedures with extraordinarily low risk - is at that high a level.



the wording is not "discuss". it is "decision to perform procedure", meaning to me that one has to do all the work to get procedure approved including but not limited to discussion with the patient.

Feel free to diminish your own value if you prefer.

People suffer permanent SCI every year from interventional pain procedures. The necessary expertise and risk is not the same as a shoulder injection.

 

[BoardingDoc]

Thanks. Does your your lumbar MBB template always include “cervical pain likely facet mediated as well”?

Lol, no. This quoted part is my macro:

"Will plan on diagnostic MBB of BILATERAL L4-5, L5-S1 at next visit with ultimate plan for RFA of the same levels.

Justification for interventional procedure:
1. Patient has moderate to severe pain 9/10 which interferes with ADLs
2. Pain has been present for >3 months and has failed to respond to conservative measures including OTC analgesics, behavior modification and home exercises
3. Patient has no untreated radicular symptoms
4. No alternative pain generator suspected beyond facetogenic pain at this time."



Everything else I wrote/dictated. This patient happened to have both L and C complaints.

 

[BoardingDoc]

im not sure that qualifies as moderate decision making (to get to 99204) because it would be hard pressed to justify that the MBB is a "minor surgery with identified patient or procedure risk factors".

I know. I brought this exact issue up elsewhere and pointed out that without PATIENT SPECIFIC risk factors, it doesn't default count. The consensus from that thread was that I was likely correct about that, but that everyone considers booking an injection to qualify regardless. That doesn't make it correct, but it does mean that this is what virtually everyone is doing for better or worse.

Regardless, it doesn't matter as I'm not using the procedure to justify a level 4.
I independently interpreted xrays and she has 2 chronic conditions (neck and back facet pain) which are worsening. The procedure is irrelevant to justifying the 99204.

 

[Ducttape]

I know. I brought this exact issue up elsewhere and pointed out that without PATIENT SPECIFIC risk factors, it doesn't default count. The consensus from that thread was that I was likely correct about that, but that everyone considers booking an injection to qualify regardless. That doesn't make it correct, but it does mean that this is what virtually everyone is doing for better or worse.

consensus on an online forum may or may not be equivalent to what a biller or an institution such as Medicare determines.

Regardless, it doesn't matter as I'm not using the procedure to justify a level 4.
I independently interpreted xrays and she has 2 chronic conditions (neck and back facet pain) which are worsening. The procedure is irrelevant to justifying the 99204.

👍agree. level 4 because of independent interpretation of xrays (more than 1)

 

[mille125]

consensus on an online forum may or may not be equivalent to what a biller or an institution such as Medicare determines.

👍agree. level 4 because of independent interpretation of xrays (more than 1)

If you are audited, you need to be able to defend it. The rules are written to have some interpretation.

E&M audits, while definitely possible, are not common. It is just low dollar and takes a lot of work vs one big operation or procedure.