November 14, 2019
We have patients who return to the clinic for results of MRI or other diagnostic tests. The physician performs a repeat exam, reviews the images, and makes a decision for surgery. We always code these as level four established visits because of the decision for surgery.
Our question is, if the treatment plan is non-operative, for example, physical therapy, injections or bracing, does this still qualify for a level four established visit?
Thanks for your inquiry. There are no encounters that automatically may be reported at a specific level of service, such as 99214, as described in your inquiry.
To report any level of service, medical necessity must support the history, exam and medical decision making performed and documented. A decision for surgery alone, just like deciding to order PT, do an injection, or place the patient in a DME, does not automatically support a level four visit.
In some cases, the physical exam done at the first encounter may not be enough to determine if someone is a surgical candidate. Following the results of the MRI and entertaining surgery as a treatment option, the findings may require expansion of the physical exam beyond what was done originally to address musculoskeletal elements related to the initial complaint.
After an MRI, time often tends to be the contributing component for selecting the level of service, instead of history, exam, and medical decision-making. This is because typically an E/M service for the condition has already been performed and the patient presents for discussion of test results, not with changes in their condition.
A level four established office visit requires that, in addition to medical necessity, two of the three key components (history, exam, or medical decision making) be met and supported at the same level.
History = Detailed
Exam = Detailed
Medical Decision Making: Moderate Complexity
Time, may be a contributing component if greater than 50% of the face-to-face time was spent counseling and coordinating care. Documentation must include the total physician or provider face-to-face time, documentation that greater than 50% was spent counseling/coordination care and documentation of this discussion.
*This response is based on the best information available as of 11/14/19.