99395 with 99213. Do you think the documentation supports the additional 99213?

cnramsey

Guru
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217
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Priest River, ID
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Primary Care Provider: MD
Accompanied by: Self
Visit Type: New Visit

Chief Complaint: Annual PE

History of Present Illness:
Patient is a Years Old Female who presents for an annual health maintenance exam.

Last LMP: x/xx/xx
PAP Smear (21-30 q3yrs; 30-65 q5yrs when HPV cotested): normal
Fall Prevention: (Get up and go test) + Vit D + hx of falls/mobility issues; no issues
Skin Evaluation: No issues
Depression screening: patient declined PHQ9

Patient has a history of HLD, but is not currently being treated. Last fasting lipid panel showed the following in 2018:
Cholesterol: XXX
LDL: XX.X
HDL: XX
Triglycerides: XXX
Current medications include: none

She needs to have her thyroid labwork checked again. Her TSH is often suppressed but her T4 and T3 are normal. She is very hesistant to change her medications despite the risks of hyperthyroidism being discussed at length.


Problem List Changes:
Added new problem of Encounter for general adult medical examination without abnormal findings (ICD10-Z00.00)
Assessed Encounter for general adult medical examination without abnormal findings as unchanged
Assessed Hypothyroidism as unchanged
Assessed Hyperlipidemia as unchanged
Assessed Thrombocytopenia as unchanged

Medication List: (Reviewed and Updated)
Allergy List: (Reviewed and Updated)

Medical History: (Reviewed and Updated)
Hyperlipidemia
Hypothyroidism (thyroid US pg 105 records) - on combination of armour thyroid, levothyroxine
IBS - diarrhea predominant
Migraine w/o aura
Hx of thrombocytopenia, leukopenia

Fibromyalgia - gabapentin, amytriptyline, cyclobenzaprine
?Asthma vs. bronchospasm
Intermittent HTN

Tdap 20XX
Yellow fever 20XX

GYN:
GXPX00X - SVDs xX ) s/p LTC/S xX, initial for breech
- gestational HTN, thrombocytopenia

Pap 20XX, normal

Surgical History: (Reviewed and Updated)
Lap cholecystectomy (20XX)
Sinus surgery (19XX)
Oral implant, hx of oral surgery
LTC/S x X - initial for breech
BTL (20XX)

Social History: (Reviewed and Updated)
Married
Lives in
- X children

Family History: (Reviewed and Updated)
Mother - X
MGM - X
MGF - X
PGM - X
PGF - x
Sister xX - X

OB History: (Reviewed and Updated)
Gravidity: X
Prematurity: X
Term: X
Abortions: X
Living: X
NSVD: X
Pregnancy Complications: X


Sexual History: (Reviewed and Updated)
Last Menstrual Period:X
Cycle: XX Interval: X
Flow: regular


Risk Factors:
Tobacco: (Reviewed and Updated)



Review of Systems:
General: Denies fever, chills.
HEENT: Denies sore throat, sinus congestion.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: Denies vomiting, diarrhea.
GYN: Denies dysuria, abnormal vaginal discharge.
Dermatology: Denies rash, change in moles.
Psychiatric: Denies anxiety, depression.
Hem/Lymph: Denies abnormal bruising, easy bleeding.


Vital Signs:
Weight: XXX.X lbs. Height: XX.XX in. BMI: XX.XX
Temperature:X deg F. Temperature Site: Temporal
Respiration: XX Pulse: XX Pulse Rhythm: Regular
Blood Pressure #1: XXX/XX mm Hg. Location: Arm Position: sitting

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI; conjunctiva and sclera clear.
Ears: TM's intact and clear with normal canals and pinnae.
Nose: No deformity/significant septal deviation; Normal mucosa.
Mouth: Mucus membranes moist; No erythema / exudates.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: Soft/nontender; No guarding or rebound; Bowel sounds present.
Pulses: Pulses full and equal.
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.


Assessment and Plan:
• ENCOUNTER FOR GENERAL ADULT MEDICAL EXAMINATION WITHOUT ABNORMAL FINDINGS (ICD10-Z00.00) Unchanged
Doing well overall, no specific issues.
Up to date on pap smear, otherwise normal exam.
Fasting labwork pending.
Follow up in 1 year.

• HYPOTHYROIDISM (ICD-244.9) (ICD10-E03.9) Unchanged
Main issue for patient, very hesistant to stop any thyroid medication.
Discussed the importance of not overtreating her thyroid on her long term health.
Labwork pending.
Follow up pending this .

• HYPERLIPIDEMIA (ICD-272.4) (ICD10-E78.5) Unchanged
Recheck today as labwork has not been done in 2 years.

• THROMBOCYTOPENIA (ICD-287.5) (ICD10-D69.6) Unchanged
Recheck today.


Medication List Changes:
Removed medication of X

Removed medication of X

Removed medication of X

Removed medication of X


Orders:
TSH [TSH]
T4 Free [FT4]
T3 Total [T3]
Comprehensive Metabolic Panel [CMP]
Hemogram (CBC no diff) [HGMP]
Est. Annual Exam: 18-39 [CPT-99395]
Ofc Vst; Est Level III [CPT-99213]


Portions of this report may have been transcribed using voice recognition software. Every effort was made to ensure accuracy; however, inadvertent computerized transcription errors may be present.
 
Messages
2
Location
Brooklyn, NY
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The documentation does not support that a significant, separately identifiable problem focused exam was performed. To bill for a problem focused EM in addition to an annual exam there should be separate notes for each or a significant amount of documentation within the annual evaluation note of a new or acute problem. This Provider addresses the Pt's pre-existing chronic conditions which does not meet the AMA, CMS and NCCI documentation criteria and guidelines for reporting a significant, separately identifiable problem focused EM. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (i.e., Key Components)
 

cnramsey

Guru
Messages
217
Location
Priest River, ID
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The documentation does not support that a significant, separately identifiable problem focused exam was performed. To bill for a problem focused EM in addition to an annual exam there should be separate notes for each or a significant amount of documentation within the annual evaluation note of a new or acute problem. This Provider addresses the Pt's pre-existing chronic conditions which does not meet the AMA, CMS and NCCI documentation criteria and guidelines for reporting a significant, separately identifiable problem focused EM. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (i.e., Key Components)
That was how I felt. Provider was queried and they feel very strongly that their discussion they had with the patient regarding her hypothyroidism supports this level. If she would have documented that she spent 15 mins of this visit with greater than 15 mins spent counseling her on ...... Would it had supported a 99213 charge?
 

SharonCollachi

True Blue
Messages
1,019
Location
Clovis, CA
Best answers
3
That was how I felt. Provider was queried and they feel very strongly that their discussion they had with the patient regarding her hypothyroidism supports this level. If she would have documented that she spent 15 mins of this visit with greater than 15 mins spent counseling her on ...... Would it had supported a 99213 charge?
I would still say no. It's a chronic problem, nothing new or acute. It appears her lack of compliance is not new either.
 

Eagle Eye

Contributor
Messages
14
Location
Newport News, VA
Best answers
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I agree with the other coders. Addressing chronic stable conditions, ordering labs, refilling the same medications with the same dosage are all part of the preventive exam. No separate E/M is supported.
 
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