What level of medical complexity for E&M determination?

[Creflo]

As a relatively new practitioner in the medicare world, I'd like to post a few scenarios and poll to ask what level of medical complexity you would consider. I know the rest of the note has to justify the complexity, but for medical decision making only, what level would you give the below? I'm on the fence between Straightforward and Low for the below, which way would you go?

1. Follow up visit, discover new stage 1 ulcer at tip of hammertoe, with associated hyperkeratosis. Debride the hyperkeratosis, prescribe x ray of toe, dispense crest pad.

2. Follow up visit to review toenail culture, onychomycosis is the result. Penlac is prescribed.

3. New patient with heel pain and stage 1 ulcer deep to heel callus, x ray is taken and reviewed, toenails and calluses are trimmed and billed for, and heel offloading with pillow under calves is discussed with patient. Ammonium lactate prescribed.

4. New diabetic patient, trim nails and calluses and bill for them. Prescribe capsaicin lotion for burning pain, perform diabetic foot education.

None of them have a drug requiring a prescription. A consultant seems to lean towards don't bill a low complexity unless a prescription drug is written. Thoughts?

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[dtrack22]

The answer is if the patient has commercial insurance bill level 3s minimum on all of those patients.

1. 99213 (honestly this one could be a 4 depending on what you are doing about the patient’s other or contributing chronic illnesses)
2. 99213
3. 99203
4. 99203

None of these are level 2 visits IMO. In my practice those are reserved to matrixectomy/avulsion follow ups and other msk problems who are at their last “I’m doing great don’t need anything else” appointments. Most everyone else is a level 3 and pretty much all surgical consults are level 4s

 

[AttackNME]

There are strict guidelines that constitute the elements required in your note to specify level of complexity, it isn't an opinion based answer. If you don't know and upcode based on what you feel is okay and get audited you can get in trouble. Easiest is to bill based on time and document the time spent in the encounter. If you want to learn appropriate coding, it's most efficient to request a random audit from your coding people where you work. Crefo since your doing a cash based practice I would try to get familiar with the required elements and study them on your own and build a template that satisfies those elements, good luck

 

[ldsrmdude]

There’s a good billing and coding thread in the Practicing Physician forum where a lot of scenarios are debated and discussed