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E&M coding with Fever

dappy

Contributor
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What E&M code would you use for this note? pt is a 9yr old female

Chief Complaint(s):
Severe cold

HPI:
ENT
Pt presents, accompanied by mom, 2 day h/o increased fatigue, low grade fever -Tmax 99, sore throat, decreased appetite, cough- non productive. Mom reports that a lot of children are sick in her class. Mom has not given her any medication. Mom would like pt to r/o for strep throat.
Current Medication:
Not-Taking/PRN
Cortisporin Otic 1%-0.35%-10000 units/mL otic solution 4 gtt 4 times a day

Medication List reviewed and reconciled with the patient

Medical History:
Repeat C-section 38+4 weeks

Birth weight 7-2; d/c weight 6-8.7

Mom's blood type A+; mild jaundice

RAD--home nebulizer

RSV bronchiolitis--1-09

heart murmur--w/u by cardiology at birth

Allergic rhinitis--cats

Allergies/Intolerance:
Cat - itchy eyes

Gyn History:
OB History:
Surgical History:
Appendectomy 09/2014

Hospitalization:
Denies Past Hospitalization

Family History:
Father: alive, Allergic to Amoxil
Mother: alive, Allergic to PCN
Siblings: alive, Sister allergic to Amox
Paternal Grand Father: deceased 40 yrs, Car acident--hit and run; very little family hx
Paternal Grand Mother: alive, Depression, Bipolar, Alcoholism
Maternal Grand Father: alive, unknown--never married to mom--no contact
Maternal Grand Mother: alive, Alcoholic, doesn
1 brother(s) , 1 sister(s) - healthy.
Social History:
no Other Tobacco use.
no Secondhand Smoke.
PCP Verification: done Do you consider Avance Care as your PCP? Yes.
Last CPE/Well-Child: done When? Date 09/2015.
Occupation: student.
no Abused.
Safe at home: yes.
Home smoke detector use: yes.
ROS:
CONSTITUTIONAL
Sick Contacts yes. Fever yes. Chills yes.
HEENT
no Runny Nose. no Ear Pain. Sore Throat yes. Cough yes. no Post-nasal Drip.
RESPIRATORY
no Nasal Congestion. no Shortness of Breath.
CARDIOVASCULAR
no Irregular Heart Beat. no Chest Pain.
GASTROINTESTINAL
no Nausea/Vomiting. no Constipation/Diarrhea. no Abdominal Pain.
SKIN
no Rash.


Objective:
Vitals:
Wt 72.2, Wt Change 4.2 lb, Ht 54, BMI 17.41, Temp(F) 100.2, HR 98, RR 18, BP(Systolic/Diastolic) 102/96
Past Results:
Examination:
ENT
Eyes: Bilateral conjunctiva without erythema or drainage.
Ears: No discharge, bilaterally tympanic membranes with good light reflex and pearly color.
Mouth: dry mucus membranes.
Throat: mild erythma, no exudates; , tonsils 2+ size.
Neck : enlarged nontender lymph nodes.
General Examination
General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.
Heart: Regular rate and rhythm, no murmurs.
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.
Physical Examination:


Assessment:
Assessment:
Acute pharyngitis, unspecified - J02.9 (Primary)



Plan:
Treatment:
Acute pharyngitis, unspecified
Lab:Rapid Strep (IH) (CPT 87880) Negative Result neg
Control pos
Lab:Culture, Throat (DP 10) (CPT 87070)
Notes: Rapid strep negative. Will send for cx. Will notify mom of results. Mom to alterante children's tylenol and children's motrin every 3-4 hrs for fever and pain. Mom to push fluids to maintain hydration. Mom to call with any questions or concerns. Mom voiced understanding to plan.
Procedures:
Immunizations:
Therapeutic Injections:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:

Next Appointment:
as scheduled


Thank you
 

consultingbykristin

Networker
Local Chapter Officer
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95
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I say 99202. MDM is low and while there's a lot of documentation, was it all truly necessary for this visit? Documentation volume should not be considered when assigning a code. There's a lot of family history data that's irrelevant. Also some of the HPI is the same as what is listed in ROS. We can't double dip. He said patient has a cough and fever that's HPI. For ROS, I didn't count the bullets if it was the same detail as he noted in HPI.
 

CodingKing

True Blue
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I'd have a hard time assigning anything higher than a level 2 for a case where the diagnosis is pretty much known before the patient walks in the door. If there was an OTC rapid strep test I don't even think they would have even come in the office. The only family history that would even be relevant to the case would be allergies to antibiotics otherwise it's just fluff.
 

thomas7331

True Blue
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I share the concern about the fact that the medical necessity doesn't appear to support the level of detail in the documentation, but would just urge caution in this area. I'd point out that the documentation requirements of 99203 (which is not a high-level code to start with) are met here even if you take out the more obviously 'irrelevant' information. To further disqualify history or exam elements based on medical necessity requires some knowledge of clinical practice and is something that's best pursued with the input and participation of the provider. There are often details in the patient's history that require a more extensive provider work than what might appear to the untrained observer.
 

dappy

Contributor
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My Doctor insists it is a lv 4 due to the pt having a FEVER. The doctor considers it an 'Acute illness with systemic symptoms'. :(

Thanks for all the good comments.
 
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