Wiki E&M coding help


Gouverneur, NY
Best answers
I'm struggling with the level of service of this note. Provider states severe asthma info in HPI with complex documentation. However they have a normal exam. Can there really be both according to this note?

Reason for Appointment
1. Follow up er/ asthma

History of Present Illness
Accompanied by: Mom .
5 year old female with recurrent episodes of respiratory difficulty, most of the time apparently with bronchospasm. Has received 8 short courses of steroids over the last 6-8 months. Had been on Flovent 110 2 puffs BID and has also been using Albuterol aerosols or HFA. Often at night has significant difficulty breathing especially at night. Has been to Allergist, found to be allergic to dust, cats, pollens. Family has dog at home, but no reported sensitivity to dog. Family has been using HEPA air filter in the bedroom. Mom tried Benadryl last night but it seemed to not particularly help child. Cold air seems to make it worse. Currently on day 5 of Prednisolone 30mg after being seen in ER Friday evening (48-72 hours ago). Back to ER the next night because of difficulty breathing, "and last night I just sat up with her because every time she laid down she couldn't breath." Symptoms have been occurring over the past 3 years. Pulmonary function test planned for Monday in Watertown.
Spoke with (Nurse Practitioner in Pediatric Pulmonary Division) with mom and daughter in room with MD. Much discussion, and upon recommendations of NP, will plan as noted below. Mom understands to call or return if child fails to improve over the next 24-48 hours or worsens in any way.
Some episodes of facial swelling also noted by family. Left side of face swelled on Friday evening when child was taken to ER.
Mom used cell phone to video tape child when she was breathing last night. Marked forced, prolonged expiratory phase. No obvious stridor. Audio only.
Asthma Form Coughing, wheezing, shortness of breath or tightness in the chest during the day Nearly every day, Coughing, wheezing, shortness of breath or tightness in the chest at night Frequently/every night, Asthma severity classification Severe Persistent.

Current Medications
TakingPrednisoLONE 15 MG/5ML Solution 2 tsp po now and qam x 4 days more Orally qAM
Ventolin HFA 108 (90 Base) MCG/ACT Aerosol Solution 2 puffs as needed Inhalation every 3 hrs
Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization Solution 3 ml Inhalation every three hours PRN
Flovent HFA 110 MCG/ACT Aerosol 1 puff Inhalation Twice a day
Not-TakingBudesonide 0.5 MG/2ML Suspension INHALE ONE VIAL VIA NEBULIZER TWICE A DAY
Pulmicort 0.5 MG/2ML Suspension 2 ml Inhalation twice a day (bid) PRN
MiraLax - Powder mix 17grams with 8 ounces of water as directed Orally Once a day
Medication List reviewed and reconciled with the patient

Past Medical History
Possible movement disorder - monitoring

Surgical History
Social History
Same Day Appointment Offered: Yes, Date 10/09/2015, Scheduled/Accepted Yes.

Hospitalization/Major Diagnostic Procedure

Vital Signs
Temp 98.7, HR 82, BP 94/60, RR 20, Wt 60, Ht 49.25, BMI 17.39, BMI Percentile 88.92.

Pediatric Female:
GENERAL: well developed, well nourished, NAD, alert and playful. SKIN: no rashes. HEAD: normocephalic. EYES: sclera w/o injection. EARS: TM's normal bilaterally. NOSE: nasal discharge. ORAL CAVITY: moist mucus membranes, tonsils normal. NECK: supple, full range of motion. CHEST: clear to auscultation with good air exchange bilaterally; no wheezes/rales/stridor; pink and comfortable in room air. HEART: no murmurs, regular rate and rhythm. ABDOMEN: soft without hepatosplenomegaly, without masses, nontender. EXTREMITIES: all move well. NEUROLOGIC EXAM: intact. LAB TESTS REVIEWED Pulmonary Functions today: normal for age.

1. Asthma - J45.909 (Primary), Severe Persistent
1. Asthma
IMAGING: Pulmonary Function Test
Notes: Add Singulair 5mg PO QD, first dose now.
Add Cetirizine 5mg PO QAM, first dose now.
Continue current care.
Pediatric Pulmonary consultation ASAP.

2. Others
Start Cetirizine HCl Syrup, 1 MG/ML, 5 ml, Orally, qAM, 30 day(s), 150 Milliliter, Refills 3
Start Montelukast Sodium Tablet Chewable, 5 MG, 1 tablet, Orally, qAM, 30 day(s), 30 Tablet, Refills 3
Refill PrednisoLONE Solution, 15 MG/5ML, 2 tsp po now and qam x 4 days more, Orally, qAM, 5 days, 50 Milliliter, Refills 0
Last edited by a moderator:
I would think it could be possible to have a normal exam if the patient is not having an episode at the time of the visit, but only the provider could answer this definitively. It might be a point of discussion you could have with the provider - if it's a pattern you're seeing, the provider might be using their exam templates incorrectly. But it shouldn't affect your coding - I would still code the visit based on the key elements present in the note.
additional help please

so new question. my first impression with complex HPI and detailed remainder of note that a 99214 was appropriate. However the provider coded 99215 and I'm not sure I agree per the documentation after the HPI. Did you ever have one of those days where you can't comfortable answer your own questions. Thanks SB
I would be comfortable accepting the provider's coding of 99215 and feel that I could make a good defense for that if audited. I get a comprehensive history and exam (8 organ systems). MDM could be counted as moderate or high, depending on whether you count the problem as established and worsening or new with additional workup, which is moot anyway since you only need two of three. I think the medical necessity for level 5 service is well supported based on the documentation of the severity of the problem and the urgency of the treatment plan.
Just a correction to my previous post - the documentation doesn't appear to have a ROS other than what is in the HPI, so technically this wouldn't qualify as a comprehensive history. That could tip this toward 99214 but I'd still stand by what I mentioned before that there's an argument for high complexity MDM here which would still support 99215. Hope that helps some. I agree, sometimes you just have one of those days!:)