
Coding & Documentation
Fam Pract Manag. 2022;29(5):36
Author disclosure: no relevant financial relationships.
AMBULATORY BLOOD PRESSURE MONITORING DATE OF SERVICE
METERED-DOSE INHALERS
RETINAL IMAGING SCREENING FOR DIABETIC RETINOPATHY
Editor's note: A previous version of this Coding & Documentation question included outdated information. The codes changed in 2021. The information has been corrected below.
If specially trained clinical staff perform the analysis and issue the report, the appropriate code would be 92227. If the ophthalmologist (or another qualified health care professional under direction of a retinal specialist) performs this interpretation then the correct code would be 92228. For retinal imaging for detection or monitoring of disease with point-of-care automated analysis, report code 92229.
ATTENTION-DEFICIT HYPERACTIVITY DISORDER PRESCRIPTION MANAGEMENT
Following the E/M guideline changes of 2021, when you provide ongoing management of a chronic condition such as ADHD, you should report an established patient office E/M service code (99212-99215) based on the medical decision making (MDM) necessary to manage the condition during that visit, including prescription drug management. Chronic illnesses without severe exacerbation or progression are typically level-3 or level-4 problems depending on how many there are and how stable they are. Deciding to continue the same medication and same dose is considered prescription drug management, which is level-4 risk.
As an alternative to coding based on MDM, you can code the visit based on your total time spent on the date of the encounter, regardless of whether that time was spent face-to-face or in counseling and/or coordination of care.