Resolved Case study for E & M Code

[RinshidaK_89540]

HISTORY OF PRESENT ILLNESS: This is a follow-up visit for this 68-year-old female. She was admitted to Nursing Home 10 days ago with cellulitis of the left foot. She was placed in there for IV therapy of her cellulitis. She is recovering well and the infection is almost gone. She has a history of type 1 diabetes.
Allergies: None
Medications: Insulin 70/30, IV vancomycin
REVIEW OF SYSTEMS: Normal.
PHYSICAL EXAMINATION: General: Well-developed, well-nourished female in no acute distress. BP 128/75. Pulse: 80, regular and strong. Respirations: 12, unlabored and regular. Temperature: Normal. Height: 5 foot.
HEENT: Normal. No lesions noted.
Skin: Left foot shows slight reddening on the upper surface. Infection had decreased significantly. All other areas are normal.
PLAN: Patient is doing well and will be taken off IV vancomycin. She will be discharged home tomorrow and will be given a prescription for penicillin. She is to follow-up in my office in one week.
History: Problem-focused
Examination: Problem-focused
Medical Decision: Straightforward
E & M Code?

99307

 

[Laureen Jandroep]

Thanks for this RinshidaK_89540 can you (or someone else) take a stab at breading down the MDM even more since that is how E&M is currently getting scored?

 

[RinshidaK_89540]

Thanks for this RinshidaK_89540 can you (or someone else) take a stab at breading down the MDM even more since that is how E&M is currently getting scored?

I am sorry, I didn't get that Laureen

 

[Darcy]

In the context of medical decision-making (MDM), Straightforward MDM is one of the four levels of MDM complexity, with the other levels being Low, Moderate, and High. Straightforward MDM is the least complex, and it typically applies to routine visits or situations that do not involve significant risk or require extensive evaluation.

The criteria for determining Straightforward MDM include:

1. Number and Complexity of Problems Addressed:
- Only one self-limited or minor problem is addressed (e.g., a minor illness or injury that is temporary and self-resolving without significant intervention).

2. Amount and/or Complexity of Data to be Reviewed:
- Limited data is ordered, reviewed, or analyzed. This could involve minimal or no diagnostic testing or a simple review of the patient’s history.

3. Risk of Complications and/or Morbidity or Mortality:
- The risk of complications, morbidity, or mortality is minimal. This usually applies to situations where there is little risk of significant adverse outcomes, such as prescribing simple medications or treatments with a low chance of side effects.

Straightforward MDM is often seen in routine check-ups or when addressing common, low-risk issues like colds, minor skin conditions, or follow-up on previously treated conditions without complications.

You may want to reference the 2021 E/M Guidelines for more details, as they outline these criteria in greater depth.

 

[JamieN_9335]

I will give it a try. Please let me know if anything was missed or if my explanation was unclear.

Number of Complexity of Problems Addressed: The cellulitis was addressed in this visit, which would count as 1 acute, direct or well-defined problem addressed. This falls in the Low Level.

Work Performed & Analyzed During the Encounter: There was no additional order, review, or otherwise classified work of the provider. This falls in the Straightforward or Minimal Level.

Risk of Complications and/or Morbidity or Mortality of Patient Management: The patient was prescribed penicillin, which would be regarded as an initiation of medication that requires prescriptive authority. This falls in the Moderate Level.

We had only had one MDM in the moderate level, so we can't use 99309. We have one MDM for the low level, but we also met and exceeded the low level due to the moderate risk category. Therefore, we have two out of three in the low category.

Answer: 99308