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Wiki E.M level

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ny2scgirl

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Location
Myrtle Beach, SC
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My provider always charges a 99214 for ADD follow ups even if he didn't change the medication. I believe this is a level two. Thoughts?





Reason for Appointment
1. ADD
History of Present Illness
Advanced Care Planning:
Here for sch'd apt
Has been doing well in school, all A's this year
Seems to have good appetite and reportedly sleeps well.
Vital Signs
Temp: 97.8 F, HR: 70 beats per min, RR: 18 breaths per min, O2 sat %: 99, BP: 108/70 mm Hg, Wt: 70.6 lbs, Wt %: 12.59 %, Ht: 57 in, Ht %: 35.21 %, BMI: 15.28 Index, BMI %: 9.35 %, Wt-kg: 32.02 kg, Ht-cm: 144.78 cm
With mom.
Examination
General Examination:
GENERAL APPEARANCE: alert, well hydrated, in no distress .
HEAD: normocephalic, atraumatic.
EYES: BOTH EYES, eyelids normal, conjunctivae normal, sclera non-icteric.
HEART: regular rate and rhythm, S1, S2 normal, no murmurs, rubs, gallops.
LUNGS: clear to auscultation bilaterally.
CHEST: normal shape and expansion.
Assessments
1. ADHD (attention deficit hyperactivity disorder), combined type - F90.2
Treatment
1. ADHD (attention deficit hyperactivity disorder), combined type
Refill Concerta Tablet Extended Release, 54 MG, 1 tablet in the morning, Orally, Once a day, 30 days, 30 Tablet, Refills 0
Notes: Attention Deficit Hyperactivity Disorder (ADHD) in Children: Care Instructions material was published
Clinical Notes: doing well on current dose
Follow Up
4 Months (Reason: add)
 
The "always charges a 992_ _" thing is generally going to be a red flag. The level will always be dependent on the documentation.
If this is office/outpatient later than 2021, and no time is documented, and what you have above is the whole note:
1. Low/Minimal/Moderate = 99213*. I agree with you it is not level 4.

I would have a talk with my provider if they "always" charge the same level all the time to every patient.

*edited to fix EM level and adjust from 99212 to 99213.
 
Last edited:
I'm confused as to how you got level 2 from a low problem, which is level 3, and moderate management, which is level 4. That would make it level 3, not 2.

As ADHD is a problem that does not go away (a chronic problem), but seems stable as the patient is doing well and no other documentation to suggest otherwise, would make this a stable chronic problem with moderate level management - 99213.

EDIT: I do, however, agree that any provider who "always" charges a specific level for any and/or all patient visits is a problem and the provider needs to be educated on that.
 
carlystur said:
I'm confused as to how you got level 2 from a low problem, which is level 3, and moderate management, which is level 4. That would make it level 3, not 2.

As ADHD is a problem that does not go away (a chronic problem), but seems stable as the patient is doing well and no other documentation to suggest otherwise, would make this a stable chronic problem with moderate level management - 99213.

EDIT: I do, however, agree that any provider who "always" charges a specific level for any and/or all patient visits is a problem and the provider needs to be educated on that.
Click to expand...
You are correct, sorry for the bad info, I was reading and typing fast. I will edit my post to adjust.
 
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