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MDM in E/M Coding

Kirsten Posted Thu 22nd of October, 2015 10:53:09 AM

Greetings! I am a coder at a surgeon's office. I am trying to code a post-op visit for a patient that had a colonoscopy. She has a history of colon carcinoma in situ. Her biopsies from this colonoscopy showed dysplasia. The surgeon has recommended another colonoscopy in 3 months. If dysplasia is seen again, a resection may be in order. How do I code the E/M portion of this visit? Under the "Number of Diagnoses or Treatment Options" I listed "Established problem to examiner; Stable or Improved. (Because it did not show carcinoma in situ anymore). That counts as 1 point. He reviewed the pathology report with the patient which is 1 point for "Complexity of data reviewed". I listed "Moderate" for level of risk because of her upcoming minor procedure. Based upon this, I have a "Straight Forward" for "Number of Diagnoses" and "Amount/Complexity of Data Reviewed", or 99212. This visit seems more than that. What is the MDM for an established problem to examiner with additional workup planned including further surgery?

SuperCoder Answered Fri 23rd of October, 2015 06:14:23 AM

Thanks for your question

As per the given scenario, CPT code choice 99212 is correct.

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