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Case of the Week
New Patient: Complex Chronic Care
Test our E/M-Code-Sense AI! Copy the clinical note below and paste it directly into the free trial calculator to see the audit-proof code instantly.
Click to Reveal the Answer & Analysis
The Correct, Audit-Proof Code Is:
99205
This complex new patient encounter achieves the highest possible level of care based entirely on Medical Decision Making.
Medical Necessity, Proven.
A Level 5 visit will trigger an immediate denial if the diagnosis doesn't justify it. E/M-Code-Sense AI now automatically extracts and cross-checks your ICD-10 codes to ensure the "Why" supports the "What."
Code-Sense AI Extracted Diagnoses
- I10 Essential (primary) hypertension
- E11.9 Type 2 diabetes mellitus without complications
- N18.4 Chronic kidney disease, stage 4
- E78.5 Hyperlipidemia, unspecified
*Note: Suggested ICD-10 codes are preliminary base categories mapped by the AI to justify the E/M level. Always verify terminal code specificity prior to billing.
Why MDM Drives This Encounter
The AI calculates both Time and MDM simultaneously. In this case, billing by time would have resulted in undercoding a highly complex visit.
Time-Based Result: 99204
The total time entered was 45 minutes. This meets the exact threshold for a 99204 (45-59 minutes), but falls short of the 60 minutes required for a 99205.
MDM-Based Result: 99205
The overall MDM complexity was determined to be High. For a new office patient, High MDM overrides the time to achieve the 99205 level of care.
Code-Sense AI CDI Alert Generated
The AI caught this exact revenue discrepancy instantly and generated this Clinical Documentation Improvement alert for the user:
"The level of service was determined by High MDM. The documented time of 45 minutes only supported a Level 4 (99204) visit. To also support a Level 5 visit based on time, a total of 60 minutes or more would need to be spent and documented for the encounter."
MDM Deep Dive: Across the Board High
To score a 99205, you need two of the three components to hit the "High" level. This chart actually maxed out all three categories.
Problems Addressed: High
The patient presents with a severe progression of CKD with worsening proteinuria. This satisfies the High complexity requirement for a severe exacerbation of a chronic illness.
Data Reviewed: High
You met Category 3 via direct discussion of management with Nephrology. You also met Category 1 by reviewing a prior external note, reviewing a test result, and ordering 5 unique tests.
Risk of Complications: High
This was met in two different ways: 1) Decision regarding hospitalization (discussed IV diuresis admission), and 2) Drug therapy requiring intensive monitoring (Repeat BMP in 3 days for Lasix).
The "2 out of 3" Rule Confirms High MDM
Data
HIGH
Problems
HIGH
(Middle Value)
Risk
HIGH
The middle value is High, which becomes the final MDM level.
Stop Guessing. Start Coding with Confidence.
The E/M-Code-Sense AI doesn't just calculate your CPT code. It actively extracts your ICD-10 diagnoses to ensure your documentation survives an audit.
Accurate
Boost Your Accuracy by 42%
Our data shows that professionals using E/M-Code-Sense AI are, on average, 42% more accurate in selecting the correct level of care compared to manual methods. Stop leaving legitimate revenue on the table.
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