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down coding from 99214 to 99213

K Posted Thu 31st of October, 2019 10:36:48 AM
Hello, Our provider feels his office visits support a 99214 due to pain management with patients that are being treated with pain meds. The patient has a work comp approved claim. The provider documentation has ROS of 7 systems, pain assessment with location, rating, description of pain, vitals, goes over patients history, does a PE of upper/mid back, motor and reflex, and medical management. Patient is on pain meds ( Norco ) reviews CURES plus reviews all other meds and gives a prescription for current pain medication. The patient also is prescribed Narcan and the provider counseled the patient on medications. The provider follows the MTUS guidelines for intractable pain act of CA. What support can we use for our appeal to support the higher level of service due to the complexity of the medications the patient is on? We are having more issues with the down coding of our E&M codes from 99214 to 99213. Thank you for any help!
SuperCoder Answered Fri 01st of November, 2019 07:48:40 AM

Hi,

Please find the below link to correlate to your documentation and how patient under CURES consult are considered as high-risk patients. 

https://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Opioids-ChronicPain/Final-Regulations/CleanCopy/Opioids-Guidelines.pdf

Patients with ROS 7, with chronic pain and Norco med will support 99214.

However, you may send us more details to support higher level of service. Thank you.

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