Help choosing an E/M level

Trendale

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How would you code this? The physcian wants to code a level 4.

History OF PRESENT ILLNESS: This is a 51-year-old homeless male
admitted through the emergency room last night with generalized
weakness, alcohol intoxication, shortness of breath, cough, low-grade
hemoptysis, and right lower lobe infiltrate. Patient has a history of
heavy tobacco abuse and alcohol abuse. He was hospitalized here in
December, January 2009. At that time he had some patchy upper lobe
infiltrates and bilateral pleural effusions on chest CT scan, treated
for bronchitis exacerbation, and resolved. He was recently in shelter
and had an episode of seizures. He states he fell, hit his head, lost
consciousness, and was seen in the emergency room somewhere where he
had some staples put in. He had no further seizures, but has
obviously been drinking and presented this time with alcohol
intoxication. He has had increased cough, some yellow sputum
production, some increased shortness of breath other than baseline.
He smokes. He has about a 30 to 40-pack-year smoking history,
continues to smoke a pack of cigarettes daily and drinks heavily. He
reports no known history of tuberculosis in the past. No intravenous
drug use and no history of HIV exposure by his history. He denies any
other significant environmental exposure history.
PAST MEDICAL HISTORY: Has a past history significant for hypertension
and history of depression.
ALLERGIES: Denies any drug allergies.
SOCIAL HISTORY: Heavy smoker as mentioned. He worked as a welder in
the past and had some exposure possibly in that environment. He has
been homeless for about 7 years.
FAMILY HISTORY: Significant for coronary artery disease, ASCVD.
REVIEW OF SYSTEMS: Noncontributory except what is listed.
PHYSICAL EXAMINATION: Reveals a well-developed male. He is unkempt,
in no acute distress. He is pleasant. Temperature last evening was
100.9, currently afebrile. Blood pressure 129/70, pulse is 100 and
regular, respiratory rate is 18, nonlabored. HEENT reveals poor
dentition. The oropharynx without lesions. No exudates seen in the
posterior pharynx. NECK: Supple, trachea is midline, no adenopathy
appreciated in the supraclavicular or cervical region. CARDIAC:
Regular rhythm, normal S1, S2, no gallop, no JVD. LUNGS: Reveal
slightly decreased breath sounds. Minimal right basilar crackles. No
wheezes heard. Normal resonance to percussion. Good air entry in the
upper lung zones bilaterally. No rhonchi. ABDOMEN: Soft and
nondistended, nontender, no organomegaly detected. GENITOURINARY AND
RECTAL: Deferred. EXTREMITIES: Reveal no peripheral edema,
clubbing, or cyanosis. No palpable cords. NEUROLOGIC: Grossly
nonfocal.
LABORATORY DATA: Sodium 143, potassium 4.1, bicarbonate 33, BUN 4,
creatinine 0.8. Liver function studies normal. Ethanol level on
admission was 390. Dilantin level less than 1. Theophylline level
less than 2. Tylenol level negative. Troponin 0.01. White count
7300, hemoglobin 14.4, platelet count 123,000. Sputum culture thus
far negative. Blood cultures negative today times 2. Chest x-ray
shows right basilar infiltrate portable film. No cavitary infiltrate
is seen. No significant effusion noted. Heart size appears normal.
CT of the chest from January 2, 2009 did show bilateral pleural
effusions, moderate in size, right greater than left, some compressive
atelectasis and subtle vague reticular nodular infiltrate in the left
upper lobe greater than the right. Borderline enlarged lymph nodes
evident.
IMPRESSION:
1 Heavy tobacco abuse.
2 COPD (chronic obstructive pulmonary disease), chronic bronchitis.
3 Right lower lobe pneumonia suggested.
4 Low-grade hemoptysis likely secondary to above, rule out TB
(tuberculosis) given the patient's social status and hemoptysis.
5 Reported recent weight loss.
6 Alcohol abuse with intoxication on admission.
7 Homeless status.
8 History of seizure disorder with subtherapeutic Dilantin level.
9 History of depression in the past.
RECOMMENDATIONS: Will await sputum for AFB stain and culture. Place
PPD skin test. PA and lateral chest x-ray as well as follow up chest
CT scan in light of his previous adenopathy. Given his weight loss,
will go ahead with T-cell profile studies. Smoking cessation was
advised. Unfortunately, his social status and homeless status,
inability to obtain insurance and medications greatly impair his
ability for ongoing self-care and medical care.


I believe the statement for the ROS is invalid. According to the guidelines at least 1 pertinent ROS should be listed following the statement," the remainder of the ROS is negative and noncontributory to the present illness, or just list all 10 ROS, otherwise, 2-9 is a detailed level 3, but regarding the statement documentd for the ROS, I am not even sure how to choose a level based on that. I am having this issue very often with other physcians, where the ROS is taken likely, and they are expecting to get a level 5. This is a prime example. another example, they may check 3-4 systems, hit a high in the other components and expects a level 5.
Please let me know your thoughts and recomendations. Thanks in advance!;)
 

ARCPC9491

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You can use what is listed in the HPI section for the ROS as long as you aren't using them for the HPI as well. Example would be: shortness of breath, respiratory. nkda, allergic/immunologic.

To name a few HPI quickly you could use.... Right lower lobe for location, low-grade for severity, etc...
 
Last edited:
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Hi,
ROS given - Non contributory other than listed-
Listed under History -
Bilateral pleural effusion, cough, lung infiltrates;(respiratory)
Seizure -(neurological)
Drug abuse;(can consider cardiovascular; as has also past history of hypertension)

When CVS and neurology covered in physical exam particularly and this same ROS mentioned in this history, may be 99284 can be considered (the medical decision making does not include comorbidities and high level severities, as TB tests need to be taken only; So, level 4) as suggested by your doctor may be rendered;

Lavanya Mohan
 

Trendale

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reply

Hi,
This is an initial inpatient consult, which requires a comprehensive ROS for level 4 and 5 (10 systems)
So would you still say level 4 for initial consult?
I don't see 10 RoS in the history. I thought location is used for HPI, not ROS?
 

dmaec

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?? comprehensive ROS?
Inpatient Hospital Consult needs
COMP - HISTORY (ROS is part of the history)
COMP - EXAM
MOD - MDM
(to be a level 4)....
 
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Not 10 systems in ROS

Here's what I get from the HPI paragraph:
HPI: Location - right lower lobe // Duration - last night // Severity - low-grade // modifying factor - alcohol & tobacco abuse.

ROS (beginning with sentence "He was hospitalized here ..."
Respiratory (upper lobe infiltrates, etc)
Neuro (seizures)
Integ (scalp laceration - implied because he had staples put in his head after a fall)
Psych (alcohol abuse)
Allergy/Immunologic - Negative for TB or HIV

So I only get 5 systems. Not enough to qualify for a 99254 (although it WOULD be enough for the ER doc to code 99284)

If the physician had stated "All systems reviewed and negative except for those listed in the history" he would have a complete ROS (depending on your local carrier - WPS accepts this statement; other carriers want the systems listed individually).

F Tessa Bartels, CPC, CEMC
 
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Trendale

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reply to FtessaBartels

I agree with you, this is how I see it. I didn't know I can pull the ROS from the HPI. I know it is part of the history, I thought the physcian would still have to list it seperately. Nevertheless, I am getting 5 ROS from the HPI. I also agree it would be enough for the ER doctor to bill a level 4 (99284), it's a detailed history, and a detailed HX for ER constitutes a level 4, However; for an initial inpatient consult such as this, a detailed HX constitutes a level 3.
Thank you for every one's input!;)
 

Gemini18

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99223 or 99221?

57-year old female patient wit hx of diabetes mellitus, hypertension, hyperlipidemia and lung cancer diagnosed in April 2008, status post surger and on chemotherapy. Presented to ER after she has a fever and malaise for two days duration. She denied other complaints. She denied any cough. No chest pain or discomfort. She had mild loose stool which has not persisted, but she has no abdominal pain. No urinary complaints as well. She felt for the last 2 days mild weakness and fever, and she decided to come to the ER. She was diagnosed with left upper lobe lung cancer in April 2008, and lobectomy was done at that time. She is getting chemotheraphy tomorrow with another cycle. She is following with PCP.

Review of Systems: A 10-point review of systems is noncontributory except as dictated in HPI.

Allergies: she is allergic to CODEINE.

Social History: Married, lives in Anywhere, USA. She denied smoking, alcohol or drug use.

Past Medical: 1. Diabetes Mellitus on insulin. 2. Hypertension, 3. Hyperlipidemia, 4. Lung cancer status post level lobectomy and on chemotheraphy.

Home meds: listed.

PE: General, HEENT, NECK, CHEST, CARDIOVASCULAR, ABDOMEN, EXTREMITIES, CNS

LABS: BLOOD WORK
CHEST X-RAY

Assessment: 1. Fever, 2: Acute Renal failure, 3. Urinary tract infection, 4. Lung cancer, s/p lobectomy and on chemotheraphy


I got a 99221. Please tell me if I'm wrong.

Thank you in advance.
 

Karolina

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Reply to Gemini18

I agree with you. 99221 - there is only a detailed history, the word "noncontributory" does not support the ROS and you can only count those systems listed in the HPI section (those that are not counted towards the HPI), I also don't see any Family history.
 
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