Cure What Ails Your Physician Documentation

Three common cases illustrate how to match
presenting problems with documentation and coding.

Providers are in the midst of the hustle and bustle of cold and flu season. To meet the challenge with a little more confidence this year, review the following three common case examples of established patients. You’ll see how much easier it is to code encounters that are properly documented, and learn what to ask for when they aren’t.

Case No. 1 is a very straightforward visit, much like many of us will see as a walk-in late Friday afternoon. A problem-pertinent history of present illness (HPI) was obtained, an expanded problem-focused exam was performed, and little medical decision-making (MDM) was needed. Remind providers to document for medical necessity: Additional documentation for a straightforward complaint is not required or indicated.

Case No. 1

Evaluation and Management – CEMC

Chief Complaint: Sinus infection since Sunday

History of Present Illness: Patient is a pleasant 81-year-old female with sinus congestion, cough, and nasal discharge for the last five days.

Allergies: No known allergy

Patient History

Current Medications:

1. Ezetimibe/Simvastatin 1 tablet of 10-40 mg by mouth at bedtime

– Start Date: 02/21/2012                    – End Date:                              – Quantity Dispensed: 90 tablets        – Number of Refills: 3

2. Ibuprofen 2 tablets of 200 mg by mouth 3 times a day as needed for pain

– Start Date:           – End Date:             – Quantity Dispensed: 540 unknown*                – Number of Refills: 0

Vital Signs:

-2013-10-09 0843 TEMP-ORAL: F 97

-2013-10-09 0843 PULSE-RADIAL: per min. 76

-2013-10-09 0843 RESPIRATIONS: per min. 16

-2013-10-09 0843 SYSTOLIC B/P: mmHg 126

-2013-10-09 0843 DIASTOLIC B/P: mmHg 72

-2013-10-09 0843 HEIGHT: ft/in 5.5

-2013-10-09 0843 WEIGHT: lbs/oz 156.0

-2013-10-09 0843 BMI: 25.96

Physical Examination: She is an alert and talkative female; does not appear in acute distress. Nares show some mild purulence. Tympanic membranes are translucent and gray. Oropharynx is without erythema. Neck is without lymphadenopathy. Lungs are without wheezing or crackles. She does not appear toxic.

Diagnostic Studies

– Pulmonary function tests were performed, see under flow sheets.


PROBLEM 1: Sinusitis


PROBLEM 1: Sinusitis

–       Amoxicillin 875 mg b.i.d. for 10 days. Push fluids. Tylenol. Call or return if symptoms do not resolve.

–       Coding for Case No. 1: 99212-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making-Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, plus 94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and review and interpretation by a physician or other qualified health care professional for the pulmonary function tests.

–       The physician in this case included enough HPI to give you a good background on the patient’s complaints without giving you information you do not need.

The social history is important in Case No. 2 because the patient is a former smoker presenting with a cough. The review of systems (ROS) is problem-related, and the exam is related to the systems involved, as well as to the heart and abdomen. The medical decision-making is a little more complex because of the multiple prescriptions, but all of the information in the visit is expanded problem-focused.

Here again, the provider documented appropriately for the type of patient complaint.

Case No. 2

Chief Complaint: Infection – EENT

History of Present Illness: A 56-year-old divorced gentleman is in for nasal congestion and cough he has had for almost two weeks. The cough interferes sometimes with sleep at night and during the daytime. He has tried cough syrup with little to no benefit. He mentioned that it could be related to his Lisinopril; although, he has been on that a long while and does not think it is due to that at this time. In the future, if it persists we might want to switch to Loratadine, which was prescribed during a previous visit.

Allergies: No known allergy

Social History

Marital: Married. Children: 3

Tobacco use: Former smoker. Notes: Quit in Jan. 1996

Alcohol use: Drinks socially

Current Medications: Lisinopril

Review of Systems

Cardiovascular: No chest pain, palpitation. Respiratory: Cough, fairly non-productive. No fever.

Vital Signs

HEIGHT/WEIGHT: 5 ft 9 in\260 lbs 2 oz

BMI = 38.41

BSA = 2.39

Physical Examination: Pupils are 2 mm and reactive. Ears, normal TMs and canals. Mouth, normal mucosa and gingiva. Neck, no adenopathy; thyroid not enlarged. Lungs clear, symmetric to A&P. Heart regular, no murmur. Abdomen nontender, no hepatosplenomegaly.


PROBLEM 1: Congestion with cough.


– Congestion with cough: Wrote for guaifenesin with codeine 2-3 tsp hs or q 4 hr p.r.n. nighttime cough, 8 oz two refills and guaifenesin with DM 2-3 tsp q 4-6 hr p.r.n. daytime cough, 8 oz four refills. Benzonatate 200 mg q 8 hr p.r.n. cough that can be added to the cough syrups, #50 with five refills. He is on BiPAP every night on a long-term basis. He does have some bronchospasm and we will temporarily, at least, give prednisone burst 10 mg tablets 4 a day for 2 days, 3 a day for 2 days, 2 a day for 2 days, 1 a day for 2 days and discontinue. For daytime congestion, pseudoephedrine 120 mg 12 hour preparation taken in morning. Should fade out by night. Can interfere with sleep if he takes later in the day or takes the 24 hour preparation by mistake.

– Lisinopril 10 mg at hs, which he is already using, can be continued.

– Recheck planned in 6-8 weeks. He can let us know sooner if he has any questions or problems on these new medications.

Coding for Case No. 2: 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.

In Case No. 3, the patient presents with more complex complaints; therefore, the physician’s documentation is much more detailed. In the history portion of the note, you are given detailed information about the present chief complaints, as well as the past, family and social histories and ROS. The exam gathers detailed information involving all systems that may be related to the chief complaints. Lastly, the MDM rounds out the visit by ordering necessary radiological studies, ordering prescriptions, and scheduling a re-evaluation.

Case No. 3

History of Present Illness: Patient is a 66-year-old male who comes in with complaints of moderate shortness of breath that has been going on for about the last week and a half, almost two weeks. He started to develop a productive cough, feels like he is wheezing in his chest. He has used his albuterol inhaler, but this has not helped much. A returning patient, he is not retaining much in the way of fluid as he does have a history of CHF, but he has noticed about a three-pound weight gain over that time. He has been taking furosemide once daily, and is wondering if he should bump it back up to b.i.d. for a short period.

Review of Systems

– He has had chills, but no fevers or sweats. No nausea, vomiting, or diarrhea.

Allergies: No known allergy

Patient History

PROBLEM LIST:  CHF w/cardiomyopathy, COPD, diabetes mellitus type 2, hypertension, seasonal allergies, rhinitis with RAD, obstructive sleep apnea on CPAP, hypercholesterolemia, hyperlipidemia, difficulty sleeping, RAD

MEDICAL HISTORY: Zostavax, (03/2012), PSA (2011), mammography (03/2010), Td (2005), pneumonia shot (2005)

SURGICAL HISTORY: Left eye vitrectomy (05/2013), implantable defibrillator and pacer (02/2007), right rotator cuff repair (01/1991), vasectomy (01/1982)


Occupational status: Retired hydrogeologist, part-time driving school bus. Marital status: Divorced, wife Margaret married 30+, divorced 7 years, still living together. Hobbies: Photography in spare time. Drug use: No current drug use. Tobacco use: Former smoker, 10 pack per year history, quit in 1979.

Current Medications:

-Albuterol sulfate 1-2 puff of 90 mcg/actuation using inhaler every four hours as needed, amlodipine 1 tablet of 10 mg by mouth once a day, aspirin 1 tablet of 81 mg by mouth once a day, carvedilol 2 tablets of 25 mg by mouth twice a day as directed, digoxin 1 tablet of 250 mcg by mouth once a day.

– Dulera 1 puff of 200-5 mcg/actuation using inhaler twice a day.

– Furosemide 1 tablet of 40 mg by mouth twice a day.

– Humalog KwikPen 60 pen injector of 100 unit/mL subcutaneously 3 times a day, hydralazine 1 tablet of 10 mg by mouth 3 times a day, Lantus SoloSTAR 60 pen injector of 100 unit/mL (3 mL) subcutaneously every evening, Lantus SoloSTAR 50 unit of 100 unit/mL (3 mL) subcutaneously once a day, levaquin 1 tablet of 500 mg by mouth once a day, Lipitor 1 tablet of 80 mg by mouth once a day as directed, losartan 1/2 tablet of 25 mg by mouth once a day, NovoFine 30 inject 3 times daily with NovoLog 2 times daily with Lantus, Onglyza 1 tablet of 2.5 mg by mouth once a day, selenium sulfide a small amount of 2.5% to skin twice a week, Spiriva with HandiHaler 1 capsule of 18 mcg as directed once a day, TRUEplus lancets 1 lancet of 30 gauge 4 times a day, TRUEresult blood glucose system 1 kit as directed, as needed, TRUEtest test strips 1 strip to skin 4 times a day as needed.

Vital Signs:

Height/Weight: 6 ft 0 in\317 lbs 0 oz

BMI = 42.99

BSA = 2.7


-2013-10-09 1432 TEMP-ORAL: F 97.6

-2013-10-09 1432 PULSE-RADIAL: per min. 76

-2013-10-09 1432 RESPIRATIONS: per min. 20

-2013-10-09 1432 SYSTOLIC B/P: mmHg 140

-2013-10-09 1432 DIASTOLIC B/P: mmHg 72

-2013-10-09 1432 HEIGHT: ft/in 6.0

-2013-10-09 1432 WEIGHT: lbs/oz 317.0

-2013-10-09 1432 BMI (body mass index): 42.99

-2013-10-09 1432 BMI Percentile

Physical Examination

In general, well-developed, well-nourished, very pleasant white gentleman who is in no acute distress. HEENT exam normocephalic, atraumatic. Pupils are equal, round, reactive to light. Tympanic membranes are clear x2. Oropharynx is clear. Neck is supple without lymphadenopathy; there is no thyromegaly noted. Heart was regular without murmurs. Lungs have decreased air entry bilaterally. He has faint end-expiratory wheezes, mostly in the upper air fields bilaterally, no rhonchi or rales, no accessory muscles in use. Lower extremities have trace pitting edema bilaterally.

Diagnostic Studies

X-ray of the chest and an O2 saturation was obtained. His O2 saturation was 96% on room air. Chest X-ray shows some mild vascular engorgement, but no infiltrates to my examination.


PROBLEM 1: 66-year-old male with COPD with some acute bronchitis episode. At this point, I would prefer to stay away from prednisone, but he may end up needing this with his respiratory tightness, although it would make his sugars go haywire. Will try without. Continue with his Dulera and albuterol and will put him on a Z-Pak as directed.

PROBLEM 2: Mild CHF exacerbation. Will bump up his Lasix to 40 mg b.i.d. for the next week and then down to once daily. I will see him for re-evaluation early next week.

Coding for Case No. 3: Report 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity with 71020 Radiologic examination, chest, 2 views, frontal and lateral for the chest X-ray.

Medical Necessity Is of Central Importance

The visits reviewed above are typical well-documented visits for the upcoming cough, cold, and flu season. Share these examples with your providers and work with them to fine tune their documentation.

Remember: Medical necessity should be the driving force behind documentation. Help your physicians understand that more is not always better, and that sometimes it may be unnecessary.


Bio: Angela G. Larson, CPC, is employed by the Krohn Clinic in Black River Falls, Wisc., as a full-time coding specialist and physician educator. She has been employed in the coding field for more than 12 years, coding for general surgery, podiatry, OB/GYN, inpatient services, and family practice. Larson is a member of the Wausau, Wisc., local chapter.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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About Has 393 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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