“I order liver enzymes prior to prescribing an oral antifungal. The blood work is a part of the risk and complications to determine the level of E/M. Can I also include the prescribing of the oral antifungal as part of risk and complications since it is waiting for the lab results?”
This is a really good question. Whether it is a new patient or an established patient for this specific problem, onychomycosis for this patient is to be treated via an oral antifungal medication. When you look at the Level of Medical Decision-Making Table, 2 out of the 3 Elements of Medical Decision Making need to be met. Under “Number and Complexity of Problems Addressed,” onychomycosis likely would be classified as “1 stable chronic illness.” None of the criteria are met under “Amount and/or Complexity of Data to be Reviewed and Analyzed.” Since lab work is being ordered, specifically liver enzymes, under “Risk of Complications and/or Morbidity or Mortality of Patient Management,” there is a low risk of morbidity from additional diagnostic testing or treatment.” This would translate to a CPT 99203 for a new patient/initial encounter or a CPT 99213 for an established patient encounter.
The patient is rescheduled to return after the lab results are reported to determine whether or not this patient can be started on the oral antifungal medication. When you look at the Level of Medical Decision-Making Table, 2 out of the 3 Elements of Medical Decision Making need to be met. Under “Amount and/or Complexity of Data to be Reviewed and Analyzed.” It makes perfect sense that there needs to be an “Independent interpretation of tests” by the ordering physician. An independent interpretation of test performed by another physician/other qualified health care professional (not separately reported) would certainly be appropriate. This would entail the review/interpretation of the liver enzymes that were performed by an outside laboratory. Under “Risk of Complications and/or Morbidity or Mortality of Patient Management,” by starting this patient on the appropriate regimen of oral antifungal medication, wouldn’t this be a moderate risk of morbidity from additional diagnostic testing or treatment? Of course it would. This is an example of “Prescription drug management.” This subsequent encounter would qualify for an established patient level 4 E/M service, CPT 99214.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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