Wiki 99214

[avrodriguez]

example, 4 y/o come with cough to my office never seen for that complain he is establish patient, he also has fever, i do a in-house flu test and is negative, I end with diagnosis of URI i give prescription for cough medication ( not over the counter ) HP! complete ROS more than 2 and complete PE, con this be a 99214 visit and why?

 

[Jessim929]

example, 4 y/o come with cough to my office never seen for that complain he is establish patient, he also has fever, i do a in-house flu test and is negative, I end with diagnosis of URI i give prescription for cough medication ( not over the counter ) HP! complete ROS more than 2 and complete PE, con this be a 99214 visit and why?

I'd call it a 99214 simply because of the MDM - prescription drugs given.

 

[avrodriguez]

I'd call it a 99214 simply because of the MDM - prescription drugs given.

another question in the MDM when you are counting the patient problems how do i distinguish if this is a self limited vrs a new problem if for example the kid is establish but he has a fever( new symptom ) which could be a self limited or something more complicated and im doing work up like flu, stop rsv CBC. do I apply the points based on my chief complain or final diagnosis after i did all the work up?

 

[SharonCollachi]

fever, cough, transient symptoms are self-limiting.

Diabetes, lupus, COPD, are usually not self-limiting - these will be ongoing issues to deal with.

Yes, a cough could end up being cancer, but is it usually? No.

 

[avrodriguez]

fever, cough, transient symptoms are self-limiting.

Diabetes, lupus, COPD, are usually not self-limiting - these will be ongoing issues to deal with.

Yes, a cough could end up being cancer, but is it usually? No.

so i apply the points( the problem points ) based on the chief complain or my final diagnosis?

 

[Orthocoderpgu]

Problem Points are based on the final diagnosis. Learning how to appropriately fill out an E/M audit sheet is confusing at first, but you get used to it. Take it slow and easy at first to make sure you are doing it correctly. Once you get to that point, your speed will increase quickly. But if you don't get to where you can fill it out correctly, the speed will never come. I've helped train several coders and the coders could not get their speed up until they could fill out an audit sheet accurately.