Part I: What are the coding documentation guidelines for Level 4, specifically 99204 and 99214 using Medical Decision Making?
Part 2: What level of E/M service does the treatment of a paronychia qualify for?
Coding Documentation Guidelines for 99204 and 99214 Using Medical Decision Making
Guidelines for Selecting Level of Service Based on Medical Decision Making
- • Four types of Medical Decision Making are recognized: straight forward, low, moderate, and high.
- • Shared Medical Decision Making involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.
- • Medical Decision Making may be impacted by role and management responsibility.
- • When the physician or other qualified health care professional is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report should not be counted in the Medical Decision Making when selecting a level of E/M service. An example would be obtaining and interpreting X-rays in the office.
- • When the physician or other qualified health care professional is reporting a separate service for discussion of management with a physician or other qualified health care professional, the discussion is not counted in the Medical Decision Making.
Level of Medical Decision-Making Table
- • The Level of Medical Decision Making Table is to be used as a guide to assist in selecting the level of Medical Decision Making for reporting an E/M service code. The table includes the four levels of Medical Decision Making (ie, straightforward, low, moderate, high) and the three elements of medical decision making (ie, number and complexity of problems addressed, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management). To qualify for a particular level of medical decision making, two of the three elements for that level of medical decision making must be met or exceeded.
- • For a Level 4 E/M service, a Moderate Level of Medical Decision Making is required.
Level of Medical Decision Making: Moderate
Number and Complexity of Problems Addressed at the Encounter:
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or
2 or more stable, chronic illnesses; or
1 undiagnosed new problem with uncertain prognosis; or
1 acute illness with systemic symptoms; or
1 acute complicated injury
Amount and/or Complexity of Data to be Reviewed and Analyzed (*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1):
Must meet the requirements of at least 1 out of 3 categories.
Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:
Review of prior note(s) from each unique source*
Review of the result(s) of each unique test*
Ordering of each unique test*
Assessment requiring an independent historian(s)
or
Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or
Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified healthcare professional/appropriate source (not separately reported)
Moderate Risk of Morbidity From Additional Diagnostic Testing or Treatment:
Examples only:
Prescription drug management
Decision regarding minor surgery with identified patient or procedure risk factors
Decision regarding elective major surgery without identified patient or procedure risk factors
Diagnosis or treatment significantly limited by social determinants of health
Level of E/M Service for the Treatment of a Paronychia
If a patient presents to the office with a paronychia of the toe, based upon the requirements described above, it would be difficult for the treatment of a paronychia to qualify for either a 99204 or a 99214 depending upon whether the patient is classified as either a new patient or an established patient.
For example, if the patient has a “slant back” procedure performed in order to resolve the pain and inflammation that is affecting the surrounding soft tissue and is then instructed to soak the toe/foot at home in the appropriate fashion and cover the affected area with a topical antibiotic and a Bandaid, this will qualify as Straightforward Medical Decision Making and would support a Level 2 E/M code.
If the patient has an avulsion of the affected nail border and a specimen is obtained of any drainage that was present and submitted to the pathology lab for a culture and sensitivity to be performed, and the patient is prescribed an antibiotic, this would qualify as Low Medical Decision Making and would support a Level 3 E/M code. Of course the E/M service would have to be performed and documented correctly as significant and separately identifiable from the procedure (ie. the avulsion) that was performed. (By the way, placing a patient on an antibiotic to treat an infection for a set period of time is not an example of prescription drug management. Prescription drug management would entail monitoring a specific medication that the patient is taking for an extended period).
This is my opinion.
Michael G. Warshaw
DPM, CPC
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