In keeping good faith with the readers of this blog, I am going to move to a “Level 2” Established patient visit. E and M University has some stats from 2003 on this, which may or may not be useful…..
Only 6.7% of Internists used this code in 2003. My guess is that it still is that way….
Why? Well, so often we do more work than the 99211 and 99212. Why? Well, this code requires
1. A problem focused history
2. A problem focused exam
3. Straightforward Medical Decision Making
Do you all remember how each of these categories is judged?
History is judged on:
A. Chief Complaint
B. HPI
C. Review of Systems
D. Review of Past Family, Social, Medical History.
A 99212 requires a Problem focused history which means you have to document a Chief Complaint and ONE HPI element. Just One.
What are the HPI elements? Well first, you need to know that there are only 2 types of HPI-Brief and Extended. What’s the difference? Glad you asked. The difference is HUGE and I just told you what was required for Problem Focused…..
Now the elements
A. Location
B. Quality
C. Severity
D. Duration
E. Timing
F. Context
G. Modifying Factors
H.Associated Signs and Symptoms
That’s it……you ONLY need one for a problem focused history. But for anything else you need 4 Elements, or the status of 4 or more chronic problems.
Think about it. A patient has pain, we ASK about PQRI (That’s 4 BTW) but do we ever document 4? We should.
Now on to the problem focused exam…..
This is probably one of the funniest of them all. Problem focused exam requires ONE Bullet in ONE organ System……..
Do you remember the Organ Systems? You can read about them and the bullets at this old post of mine.
But that would be tantamount to say. I took the Vitals……or I heard the heart.
We obviously are doing much more than that. Which is why most often our physica exams fall in the Expanded Problem focused, where you require 6 bullets in one or more organ systems. BTW you get 1 bullet for Vitals and One for General Appearance. Which you should do every time! Then you listen to the heart. Murmurs? No. 1 bullet, PMI shift No? 2 Bullet that’s 4 bullets. So do you think you could get 2 more? Yes, most often we do. Which is why you rarely use the Level 2 99212…
We obviously are doing much more than that. Which is why most often our physica exams fall in the Expanded Problem focused, where you require 6 bullets in one or more organ systems. BTW you get 1 bullet for Vitals and One for General Appearance. Which you should do every time! Then you listen to the heart. Murmurs? No. 1 bullet, PMI shift No? 2 Bullet that’s 4 bullets. So do you think you could get 2 more? Yes, most often we do. Which is why you rarely use the Level 2 99212…
In fact most things when a patient follows up are 99213 OR 99214 which will be covered shortly…..
Straightforward Medical Decision-Making is the lowest level of Medical Decision-Making. It is impossible not to qualify for it.
It requires that you meet 2 of the 3 categories with One Point in each OR one category and MINIMAL Medical Risk.
What does that entail? Well, you can review my medical decision making post or you can just see right here
2 Points-Independant review of EKG or Radiology or Specimen
2 Points-Review of Old Records
1 Point-Ordering or Reviewing Labs
1 Point-Discuss results with OTHER physician
1 Point-Ordering tests (EKG/CXR/Cath)
1 Point-Decision to obtain old records
Risk in this case is Minimal Which means “Self limited or minor problem”
Risk is determined by 3 Things
1. Presenting Problem
2. Diagnostic Procedures
3. Management Options Selected
But lastly in case you didn’t make one of the previous 2 categories….you always have medical decision making. In the case of 99212 the level of decision making is straightforward medical decision making. Which in essence means you didn’t need t o review or to think…..
What is straightforward MDM?
Straightforward Medical Decision-Making is the lowest level of Medical Decision-Making. It is impossible not to qualify for it.
It requires that you meet 2 of the 3 categories with One Point in each OR one category and MINIMAL Medical Risk.
What does that entail? Well, you can review my medical decision making post or you can just see right here
MDM is broken up into Problem Points, Data Points and Risk of Morbidity or Mortality from Disease.
Problem Points are
4 Points-New Problem, New Work up
3 Points-New Problem, No Work Up
2 Points-Established Problem, Worsening
1 Point-Established Problem, Stable
Data Points are
2 Points-Independant review of EKG or Radiology or Specimen
2 Points-Review of Old Records
1 Point-Ordering or Reviewing Labs
1 Point-Discuss results with OTHER physician
1 Point-Ordering tests (EKG/CXR/Cath)
1 Point-Decision to obtain old records
Risk in this case is Minimal Which means “Self limited or minor problem”
Risk is determined by 3 Things
1. Presenting Problem
2. Diagnostic Procedures
3. Management Options Selected
Source – Medicare25.blogspot.com
Still Conufsed? You can check the Table of Risk at EM University for further clarification.
