Wiki 99213 or 99214?

[Bernadette10]

I'm thinking this would be a level 3 because of medical necessity with low risk with 2 or more self-limited or minor problems? Even though the history and exam are detailed? There's also a full past medical, family and social history which I didn't copy. We use 1995 guidelines. Thanks for any advice.

History of Present Illness
Chief complaint cough, rhinorrhea, sore throat. Feeling feverish. Symptoms x about 5-6 days. Denies ear pain. Has been using nyquil, nothing today yet.

Also states severe dandruff, has tried several otc shampoos without improvement. Denies well water. Does not use a lot of hair products.

Review of Systems PHQ Score
Initial Depression Screen Score: 0 Fatigue:yes
Body aches:no
Chills:no
Fever:feverish to touch
HA: no
Nasal congestion:yes
Rhinorrhea:yes
Cough:yes, productive
SOB:no
Wheezing:no
Sore throat:yes
Ear pain:no
Ear drainage:no
Complains of dry itchy scalp, dandruff

Physical Exam Vitals & Measurements T: 37.3 °C (Oral) HR: 70(Peripheral) BP: 114/76 SpO2: 97%
HT: 160 cm WT: 51 kg BMI: 19.92 General: Well developed, well nourished, in no acute distress
Ears: No deformity or lesion of external ear. Canals and TM appear normal bilaterally. TM’s intact, not inflamed, with normal light reflex. Hearing grossly normal to conversational speech
Nose: moderate nasal mucosa inflammation and edema, no active drainage, denies sinus tenderness
Mouth: mild pharyngeal erythema, no tonsillar enlargement, no exudate, no petechiae
Neck: shotty anterior cervical nodes bilaterally
Lungs: clear to auscultation throughout, no wheezing, no rales. No respiratory distress
Cardio: regular rate and rhythm, no murmur
Skin: Dry thick patches of dandruff to scalp throughout, is pruritic per patient.
Mental Status: alert and oriented x3, normal mood and affect given age

Assessment/Plan
1. Seborrheic dermatitis of scalp. Will try on ketoconazole shampoo. Discussed needs to use consistently. Avoid too many hair products that dry out scalp, conditioner to ends of hair only to avoid build up. Fu with PCP if not improving over next 4-6 weeks.
2. Viral upper respiratory tract infection. Discussed exam and hx are consistent with viral illness. Advised of typical duration. Discussed antibiotics unfortunately do not treat viral illnesses, it will take time to run course- usually 7-14 days. Fluids/rest encouraged, PRN tylenol/ibuprofen for any pain. May use claritin D, robitussin for symptomatic tx. Follow up with PCP if not improving over next 7 days or significantly worsening symptoms. Patient and/or parent verbalized understanding of tx plan.
Orders:
ketoconazole topical, 1 app, Topical, 2x/Wk for 8 week(s), 120 mL, Refill(s) 1, Use 2x week x 8 weeks, then prn, Walmart Pharmacy

 

[whitey86]

99213

 

[Bernadette10]

Thank you!

 

[Pathos]

Per CPT coding guidelines, an Established Patient visit requires 2 out of the 3 E/M components (History, Exam or MDM). I have not seen any language from AMA or CMS where MDM has to be one of those two. I have however seen materials from AAPC and other entities, suggesting that MDM needs to be one of the 2 E/M components. This boils down to your practice policies and how they want to handle E/M components.

There are several issues with this, and I believe this will be somewhat resolved come 2021 with CMS new E/M guidelines...however until then, we are "stuck" with what we have from 1995/1997.

The argument I have seen for allowing History and Exam to be the two of the three E/M components, is otherwise possibly undercoding. If the MDM is "only" Low Complexity, and History or Exam is at least Expanded Problem Focused, then 99213 is likely. However, if the History and Exam are at least Detailed, then 99214 could happen. There is some discussion that the History and Exam are artificially overinflated, which would suggest MDM is the "true" indicator of the E/M visit, at least for Established Patient Visits. I can see both sides, which again leads me to suggest your practice should make and enforce a policy where this is spelled out for the providers and coders (and possibly practice managers).

CMS E/M guidelines

Hope this is helpful!