Wiki 99215 ???

[djnall]

I am reviewing some E/M coding and am stumped about these 2. Thoughts please.

First case - 18 month old comes in one day and diagnosis is epistaxis and impetigo. Bactroban prescription is given. Returns very next day for WCC and cellulitis Lt thigh & Rt knee. A WCC is done with the following information:
Nutritional history done
Current meds - claritin
NCSLV (no change since last visit - day before)
Physical assessment: height, weight, head circ, chest circ, temperature, pulse, respirations
Notations under exam: cellulitis lt thigh, r knee
Assessment
HBG 12/1
Oral lead risk is negative
Plan - 1 gm rocephin

Physician wants this coded as a 99215

Second case - 11 year old comes in for weight check and vomiting 4x's
Notations read:
NKDA
Current meds - stool softeners
Illness/Accident/ER/Hospitalization - none
NCSLV 1 month ago
CC: Loves to eat
vomiting - how long - last night 4 times, no f/d
weight/ pulse/ respirations taken
parent states: sneaking soda/ sweet tea
Expanded exam is done
Dx = Morbid obesity, allergic rhinitis ETD
35 minute counseling
claritin otc

99215???

 

[TamLee]

In the first one, are you asking about the well child visit or the first visit? If well child, you would use well E&M 99392, and the cellulitis could be considered part of the well visit. If the provider documented enough to support the well visit and wants to charge a sick ov code as well, use a modifier and charge both.
If you were referring to just the first sick visit, there is no way the nature of presenting problem would support a 99215. (even if there is enough documentation in the chart not.)

The second one, it looks like provider is documenting time. With 35 minutes face to face, that would only be a 99214.

Hope this helps!

 

[djnall]

Thank you for the help.
In the first scenario, I am referring to the 2nd well care visit. I'm not sure there is enough documentation to support both the wcc and the ov. I'm leaning towards the wcc.