CPT Blitz Practice Exam/E/M question

[JanetU]

Here's one question from the Blitz practice exam:
Mr. Peterson is seen by his oncologist, Dr. Katz, just two days after undergoing
extensive testing for a sudden onset of pain on the right side of the abdomen,
nausea, and fatigue that does not go away after rest. After a brief review of history,
Dr. Katz re-examines Mr. Peterson. The exam is documented as expanded problem
focused and the medical decision making of moderate complexity. The oncologist
spends an additional 45 minutes discussing Mr. Peterson's new diagnosis of liver
cancer, treatment options and prognosis.
What is/are the appropriate procedure code(s) for this visit?

-->I do not fully understand why 99213 is chosen. The rationale says: an expanded problem focused exam and moderate MDM meet or exceed the requirement for code 99213. For 99213, we have MDM of low complexity. How does that satisfy the requirements? I am really confused by this one. I would highly appreciate your help.

 

[Ruth Sheets]

The rationale is correct.

The "Established Patient in the Office" codes are 99211, 99212, 99213, 99214, and 99215. Each gets progressively more involved. That is 99212 is less work than 99213, and 99213 is less work than 99214, and 99214 is less work than 99215.

For each code, the description tells you the minimum amount of work that warrants that code. For example, if we have at least 2 of the 3 key components listed under 99213, but we don't have 2 of the 3 key components listed for 99214, then we code 99213.

In the problem scenario of Mr. Peterson, Dr. Katz did not do at least 2 of the 3 key components listed for 99214, that is, there was no detailed history, no detailed exam, but there was an MDM of moderate complexity. But that is only one of the key components, not the 2 that we need. So, 99214 is the wrong code.

However, as stated in the scenario we have an expanded problem focus exam and we have more than a low complexity MDM , that is , a moderate complexity MDM was done by Dr. Katz. So Dr. Katz exceeded the MDM Level required for 99213, and he met the exam level (expanded problem focused exam) that we need for coding 99213. In summary, Dr. Katz met or exceeded the requirements for 99213, so that's is the correct code.

I hope this explains what you needed to know. We also need to code for the prolonged services... but that is explained when you read the rationale.

 

[JanetU]

Ruth, your explanation makes perfect sense to me. Thank you so much for your help.