E/M for Worsening Chronic Condition

Question:

I have a patient with end stage renal disease who I saw yesterday in follow-up in the clinic. His ESRD is not at treatment goal, I recommended a fistula procedure and discussed specific risks and benefits of the procedure with the patient. What E/M level should I bill?

Answer:

ESRD is a chronic condition. If the patient is not at treatment goal as you stated, the complexity of the problem addressed is moderate. When recommending a major procedure if you discuss patient and procedure risks in detail and document this information in the note, the risk of mortality and/or morbidity of patient management is high. Based on these factors, the level of service would be moderate. Two elements must be met from the Medical Decision Making table for the level of service. Since this is an established patient, I would report 99214 (established patient office or other outpatient).

*This response is based on the best information available as of 6/05/25.