Audit question

abill_423

Networker
Messages
57
Best answers
0
How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.

CURRENT MEDICATIONS:
1. Altace 10 mg b.i.d.
2. Amiodarone 200 mg q.d.
3. Coumadin sliding scale.
4. Coreg CR 40 mg q.d.
5. Torsemide 20 mg q.o.d.
6. Repliva q 3 days.
7. Flomax .4 mg q.o.d.

PHYSICAL EXAMINATION:
Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.

LABORATORY DATA:
Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.

ASSESSMENT:
1. Acute renal failure, revolved. Renal function back to baseline.
2. Vitamin D deficiency with mild hyperparathyroidism.
3. Good blood pressure and volume control.
4. ALLERGY TO SULFA.
5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.

PLAN:
1. We put him on 800 IU of vitamin D q.d.
2. We didn't change any other medications.
3. Return in 6 months.
4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.
 
Messages
155
Location
Albany, NY
Best answers
0
Absolutely, I'd bill it a 99214. Here's why...

On quick audit, I credit:
EPF history
(1 cc reviewed, minimal HPI--more past history), 3 ROS (CV-chest pain, Resp-"shortness of air" taken from exam, but are ROS items, GU), Past history (meds, operations, hospitalizations)

Comprehensive Exam (95 DGs)

(8+ BA/OS: head, eyes, ENMT (HEENT), constitutional (vitals), CV, Resp, GI, skin, psych (alert, oriented X3)

MDM of moderate decision making
(3-4 established dx--per assessment--number of diags/treatment options, review of labs, and two or more stable, chronic illnesses per the table of risk)

2 out of three makes this a 99214

Agree?



How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.

CURRENT MEDICATIONS:
1. Altace 10 mg b.i.d.
2. Amiodarone 200 mg q.d.
3. Coumadin sliding scale.
4. Coreg CR 40 mg q.d.
5. Torsemide 20 mg q.o.d.
6. Repliva q 3 days.
7. Flomax .4 mg q.o.d.

PHYSICAL EXAMINATION:
Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.

LABORATORY DATA:
Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.

ASSESSMENT:
1. Acute renal failure, revolved. Renal function back to baseline.
2. Vitamin D deficiency with mild hyperparathyroidism.
3. Good blood pressure and volume control.
4. ALLERGY TO SULFA.
5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.

PLAN:
1. We put him on 800 IU of vitamin D q.d.
2. We didn't change any other medications.
3. Return in 6 months.
4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.
 

ARCPC9491

True Blue
Messages
700
Location
Stafford, VA
Best answers
0
How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.

CURRENT MEDICATIONS:
1. Altace 10 mg b.i.d.
2. Amiodarone 200 mg q.d.
3. Coumadin sliding scale.
4. Coreg CR 40 mg q.d.
5. Torsemide 20 mg q.o.d.
6. Repliva q 3 days.
7. Flomax .4 mg q.o.d.

PHYSICAL EXAMINATION:
Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.

LABORATORY DATA:
Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.

ASSESSMENT:
1. Acute renal failure, revolved. Renal function back to baseline.
2. Vitamin D deficiency with mild hyperparathyroidism.
3. Good blood pressure and volume control.
4. ALLERGY TO SULFA.
5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.

PLAN:
1. We put him on 800 IU of vitamin D q.d.
2. We didn’t change any other medications.
3. Return in 6 months.
4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.
I would use the exam and medical decision making:

1995, I get Comprehensive (8 organ systems) - constitutional, psych, cv, resp, gastro, musculo, skin, enmt

1997, I get Expanded Problem Focused: 1 bullet gen appear, 2 bullet psych, 3 bullet 3/7 vitals, 4 bullet ausc lungs, 5 bullet ausc heart, 6 bullet exam of abd, 7 bullet extrem for edema, 8 bullet skin exam

Medical Decision Making:
2+Est prob, stable
new prob, no work up (Vit D def)
total 4+ points

Order Labs 1 point

Risk: rx drug management (vit d) or 2 stable chronic illnesses

MDM - Moderate

Level: 99214 - i agree;)
 
Last edited:

dmaec

True Blue
Messages
1,133
Location
Hibbing, Minnesota
Best answers
0
WOW ! well - I agree with the doc - I'd call it a level 2 - here's my reasoning -
I get a Problem Focused History (appears the patient is in for a follow up of his recent issue and hospital stay - basically a lot of "previous medical history" given there in the first paragraph and not a whole lot of HPI). ROS - I get "none" or 1-constitutional if I pull it from the exam, which really doesn't matter because - my HPI is still lowest at "problem focused". PFSH - I have Detailed "previous medical" ...as I stated, the first paragraph covers that. SO - all in all - HISTORY COMPONENT is "PROBLEM FOCUSED HISTORY".
EXAM - I pull everything out of it rather than putting the constitutioanl in the ROS - and I get a COMPREHENSIVE EXAM.
MDM - I get STRAIGHT FORWARD - Established problem to examiner, labs yes, and low to moderate complication risk - either way - the MDM = STRAIGHT FORWARD
so -
HISTORY = PF
EXAM = COMP
MDM =SF
2 of 3 elements met which brings it down to the 99212. In my opinion, the doc knew this was a follow up and chose his level accordingly. Though the exam was "comprehensive", the rest of the visit was limited.
{that's my opinion on the posted matter}
 

ARCPC9491

True Blue
Messages
700
Location
Stafford, VA
Best answers
0
Here's my reasoning for MDM...

Problem Points:
Stage III Chronic Kidney Disease, Stable = 1 point
Nephrosclerosis, Stable = 1 point
(you do get credit for more than 1 est stable prob, with a max of 2)
Vit D Deficiency w/ mild hyperparathyroidism, New problem(s)
..and we can stop there, b/c we've maxed out our problem points, exceeding 4+

Labs, 1 data point

Stage III Chronic Kidney Disease, Nephrosclerosis (2 chronic conditions, stable) Moderate Risk

(Vitamin D can be rx. At a glance I thought under Plan, it said: No other changes made to prescriptions, but after re-reading, it said medications and given the dosage, it can be bought OTC. Bad judgement on my end to use in this case;))
 
Last edited:

aguelfi

Guest
Messages
332
Location
Port Charlotte, FL
Best answers
0
but the renal failure is back to normal. Documentation states that his last attack was acute and now longer applys, either way this pt has normal renal function. Where's the dx in that, it's resolved.
 

ARCPC9491

True Blue
Messages
700
Location
Stafford, VA
Best answers
0
abenson,
I'm not using the 'acute renal failure' in my medical decision making. I understand that it's resolved - but resolved or not, a patient can still have chronic kidney disease and acute renal failure at the same time - the acuity and failure to his kidneys may no longer be a threat at this time - but the CKD still exists.
 
Top