Guidance on E/M level

heartyoga

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I have attended the online seminar on E/M and need some guidance on how to level this: The numbers in parenthesis are the bullet points. Is this a 99213 or 99214 ? Thanks for your help.

Chief Complaint/History of Present Illness:
Mr. X returned to our clinic for follow-up of his CAD and hypercholesterolemia. He is a pleasant 72-year-old man with history of 3-vessel bypass at Vanderbilt in November 2013. He has hypercholesterolemia and diabetes mellitus. (three chronic illness stable)

The patient is still very active. He works at the school directing traffic. He lost eight pounds of weight. He said he is dieting. (How to count this

Past Medical History:
Abnormal Stress Test (with ischemia involving inferolateral wall and chest pain during exercise as well as T-wave flattening in V1 to V4), AP - Angina pectoris (exertional), DM - Diabetes mellitus, Presence of aortocoronary bypass graft (November 2013) (3-vessel bypass at Vanderbilt)


Procedures:
CABG - Coronary artery bypass graft (November 2013)

(?comprehensive in '97 guidelines or -expanded problem focused in '95?)

Presenting Medications:
aspirin oral 81mg (qd)
glyburide oral 5mg (bid)
Lipitor 10mg (qd)
metformin 500mg (bid)
metoprolol tartrate 25mg (qd)
Plavix 75mg (qd)


Allergies:
NKDA


Social History: Smoking Status: Never smoker. Language: English. Race: White. Ethnicity: Not Hispanic or Latino.


Family History:
Colon Cancer (Mother - died at the age of 68), Stroke (Father - alive at age of 93)


Vital Signs:
Ht Wt BMI BP - Sys BP - Dia BP - Site BP - Position
69.5 in 187 lbs 27.22 130 mmHg 80 mmHg Left Arm Sitting

Resp Temp Pulse Pulse Site Exertion O2 Sat Head Circ Pain Severity
72 bpm Radial Resting

Review Of Systems:
Constitutional: Negative for fever. Positive for weight loss of 8 lbs. Negative for weight gain. Positive for fatigue.
HEENT: Negative for blurred vision. Negative for tinnitus.
Pulmonary: Negative for shortness of breath. Negative for wheesing.
Cardiovascular: Negative for chest pain. Negative for dyspnea on exertion. Negative for palpitations. Negative for paroxysmal noctural dyspnea. Negative for syncope. Negative for leg edema.
Gastrointestinal: Negative for nausea. Negative for vomiting. Negative for constipation. Negative for heartburn. Negative for diarrhea. Negative for abdominal pain.
Endocrine: Negative for polydipsia. Negative for heat/cold intolerance.
Genitourinary: Negative for dysuri. Negative for hematuria.
Musculoskeletal: Negative for myalgia. Positive for arthralgia.
Neurological: Negative for unusual headache. Negative for dizziness. Negative for neurological deficit.
Integumentary: Negative for unusual rash. Negative for ecchymosis.
Hematologic: Negative for bleeding. Negative for bruising.

Physical Exam:
Constitutional:
General: Alert & Oriented x 3, Appeared to be in no acute distress.
HEENTe: Pink palpebral conjunctiva, Anicteric sclera.
Neck: Supple, No significant jugular venous distension, Carotid pulse appeared normal, No carotid bruit was appreciated.
Lungs: Clear to auscultation
COR: S1, S2, Regular rate & rhythm, Faint systolic murmur was appreciated, No pericardial friction rub, No S3, No S4.
Abdomen: Positive bowel sounds, Soft, Non-tender.
Extremities: No edema, No cyanosis.

Assessments:
Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (exertional)
Presence of aortocoronary bypass graft (November 2013) (3-vessel bypass at Vanderbilt)
Ischemic cardiomyopathy
Pure hypercholesterolemia
DM - Diabetes mellitus

Established problem stable 1 pt per dx = 4 or 5
MDM= Moderate complexity


Plan:
Comprehensive review of patient's history, records, lab results, work up results and medications.
Patient has some questions, they were answered to the best of my knowledge and to their satisfaction.
Moderate complexity medical decision making.
Continue baby aspirin.
Continue Plavix 75 mg once a day and Metoprolol 25 mg a day.
Lipitor 10 mg once a day.
Low salt, low fat diet.
Patient education.
Aerobic exercise and some resistance exercise.
Recommend 45 minutes of exercise 4 times a week per AHA guidelines.



Meds:
No Medication Changes
Follow-Up:
Follow up 6 months
 

thomas7331

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I would code this 99214. You have a detailed exam (5+ organ systems under 1995 guidelines) and Moderate MDM as you've noted. I'd consider this a comprehensive history but as you've pointed out, it's not clear how to 'count' the HPI. A strict auditor might say the provider hasn't given the status of the 3 chronic conditions, but since you only need 2 of 3 elements you've already met 99214 with the rest of the note so it's kind of a moot point how you count the history.
 

heartyoga

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Thanks

Thanks so much because we are having doubts. Our coder is saying this patient is not "sick" enough and more needs to be done. However, when a patient is stable, and doing the best he can to maintain his health, nothing much needs to be done. Our physician is very conscientious to not document fluff just to upcode.
 

thomas7331

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The patient is a diabetic with heart disease, high cholesterol and a history of open heart surgery and the coder does not think they are sick enough to warrant a 99214?? I would ask the coder to explain what parts of this note they think were medically unnecessary documentation that would warrant reducing the level.

I worked for two years with a hospital cardiology department which had many patients and visit notes just like this one. We were frequently audited, both internally and externally, and never had a problem with a 99214 for this type of encounter. Typically for a 99215 they are looking for the onset of a new problems or acute exacerbation requiring changes to a care plan and a more comprehensive history and exam, but 99214 is pretty standard for active management of 3 or more chronic stable conditions of this nature provided that all the required elements of documentation are present.
 

wynonna

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level 3 or 4

I agree that this is a solid level 4. The 3 chronic illnesses at top of note state that these 3 chronic illnesses are "stable." Because you have at least 10 points under ROS, this is very nearly a comprehensive History and would be Comprehensive if HPI contained at least 4 points and PSFH was comprehensive/complete.
Detailed Exam because at least 5 systems are investigated (level 4), and moderate MDM (level 4). As the other thread states, which I agree with, level 4 is found in Exam and Med Dec Making and a 99214 is correct for an established patient. (2 of 3 sections meet the minimum for a level 4--99214)
I would be very happy if all my providers notes were solidly composed as this one is.
 
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