If we bill an office visit when the retinal specialist makes the decision to  change the drug used for intravitreal injection treatment, would that be an evaluation and management (E/M) 99213 or 99214 when changing the drug?

Answer:
The decision for the injection would qualify for a moderate level of risk, as prescription  drug management of the medication. However, for the overall level of medical decision-making (MDM) to be moderate, either the problem or data would need to meet or exceed the moderate level of complexity. Usually the problem would be considered “1,” chronic illness with progression, which is a moderate level problem. Appropriate choice of E/M depends on all three components of MDM; two of three components (problem, data and risk) must have the same level of complexity.  

For E/M coding guidance visit E/M Documentation.

If you missed the 2023 Retina Coding Summer Symposium presented July 25, you can purchase the recording through Nov. 20.