Wiki E&M review help

[snjberry]

Please tell me what you would code this as...I would code 99213 (bordering non billable for such a confusing note that makes no sense) however the doctor coded 99214. Note says here for PE non done at all. No Review of Systems noted. No ROS is ever noted. Note says minimal toilet training yet and he diagnosed toilet training concerns...(you can't have concerns if parent isn't training yet???) and where did the viral illness come from. Nose discharge doesn't indicate illness or infection. Everyone has nose discharge.
Please help me make sense of this note.

Reason for Appointment
1. Headstart physical

History of Present Illness
Accompanied by: Mom
2 year old male with difficulty passing stools. Sometimes large in caliber, hard. Minimal toilet training as yet. Mom frustrated. Child also quite oppositional. Will be moving into Head Start in the fall.

Current Medications
None
Past Medical History
Healthy
Surgical History
Denies Past Surgical History
Family History
Father: Bipolar, ADHD
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Denies Past Hospitalization

Vital Signs
Temp 97.9, HR 98, RR 24, Wt 26.6, Ht 35.75, BMI 14.63, BMI Percentile 5.8.
Examination
Pediatric Exam:
GENERAL APPEARANCE: well nourished, well developed, NAD. SKIN: no rashes. HEAD: normocephalic. EYES: sclera w/o injection. EARS: TM's normal bilaterally. NOSE: nasal discharge. ORAL CAVITY: carious upper teeth. NECK: supple, full range of motion. CHEST: good air exchange bilaterally, no grunting, retractions, pink in room air. HEART: no murmurs, regular rate and rhythm. ABDOMEN: soft, no hepatosplenomegaly. GENITALIA: deferred. EXTREMITIES/BACK: all move well. NEUROLOGIC EXAM: intact.
Assessments
1. Constipation - 564.00 (Primary)
2. Toilet training concerns - V40.39
3. Dental caries - 521.00
4. Viral illness - 079.99
Treatment
1. Constipation
Start MiraLax Powder, -, take 8.5 grams with 4 ounces water or juice as directed, Orally, Once a day
LAB: HEMATOCRIT
LAB: Lead

2. Toilet training concerns
Notes: Sticker chart for toilet training.

3. Dental caries
Notes: DDS care as planned.

4. Viral illness
Notes: Symptomatic care.
Preventive Medicine
Anticipatory Guidance: Office visit-total face to face time with provider (of which 1/2 of more in counseling) 25.
Follow Up
prn,4-5 months

 

[cldavenport]

The last line the physician states that he spent 25min, 1/2 of which was counseling. This could be why he coded as a 99214. He's basing this visit on time. But, this could be questionable as he needs to elaborate a little more than just "of which 1/2 of more in counseling".

An example could be "20 of 25 total minutes spent counseling patient about...."

 

[snjberry]

I agree, but he didn't document any counseling so I can't give him credit for it. Right??? Isn't counseling documentation required? I can't tell what he counseled on and CC: states pt here for physical. I really don't know what to do. His response was...take out the CC from note. I explained I can't do that either.

 

[cldavenport]

Your correct. The CC can't be taken out. If he doesn't go into greater detail about what the counseling was about, then choosing the E/M level based on time would not be correct. The E/M level would then be based strictly on the elements documented which may change the E/M level.