Wiki HELP! E/M confusion (99214)


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The majority of the patients we code are established patients. I was taught always to use the MDM in the EM selection. However this has brought on somewhat of a confusion.
In all documentation I've researched, I've found the same thing... it only takes one element of risk to qualify for that lvl of risk. Then you only need 2 out of 3 elements to get your Medical descion making (prob points, data points, and risk).
So this is my confusion. If the patient is in for a new complaint (eg. Ear ache never been treated), which is 3 points, and the provider prescribes an RX drug, which is Moderate risk (because there is only 1 element of risk needed), then doesn't that meet a moderate medical decision making as long as the provider documents the appropriate exam or history?
With the new RAC audits, my department is at fear of up-coding. However from what I've learned about RAC audits, down-coding is just as bad.
I realize ear ach doesn't seem that important, but werent these rules put in place for us to follow? Should I down code as an unwritten rule?
I would appreciate any help, and if someone has other documentation i would reeealy appreciate it.
99214 it is

Yes - this would be a moderate level of MDM. I do coding for an Urgent Care and 99% of our patients are there for a new problem - which we always get a to the 3 for problems - sometimes 4 if we send them out for testing. An ear infection usually gets an antibiotic, which gives the risk of Moderate. Those two areas together get you a Moderate MDM! As long as the doctor documents a Detailed History and/or Exam (depending on if patient is new or established) you would definitely be within a 99214 without an issue!

As far as worrying about RAC - our Medicare carrier - Highmark - stated at a seminar on E/M coding that anytime the doc mentions an RX -new, changed, refilled or continue - the risk is automatically Moderate. That is how we base our coding!

Jodi Dibble, CPC
Exam portion of visit

During the examination, our physician always documents (a brief statement) about at least 7 different body systems, even when a patient comes in for a recheck, a few days after initial diagnosis. How do I distinguish between an "affected body area or organ system and other symptomatic or related organ systems" (Expanded problem-focused exam) and "extended exam of affected body area or organ system and other symptomatic or related organ systems" (Detailed exam). The physician wants these follow-ups coded as 99214, even though she may only spend 10 to 15 minutes with the patient.
Detailed vs EPF

I do not like to use the 2-4 systems = EPF / 5-7 systems = detailed. Why? Because the guidelines state that the difference in these two is the extent of the examination of the "affected body area/organ system."

So, I have trained my doctors that if they want credit for a detailed exam they must give me more than just one item on the affected system/body area (as per chief complaint).

What do I mean?

Let's say the patient presented with complaint of cough over 10 days. Physician diagnoses bronchitis and prescribed medication. Asks patient to return in 7 days for a check up.

Okay visit # 2 should focus on the respiratory system. If all the physician documents is "Lungs CTA bilaterally" then that is just a LIMITED exam of the affected body area/organ system. Even if the physician proceeds to document an exam of 6 other organ systems.

On the other hand, if at this follow-up visit the physician documents: "Patient in no apparent distress, breathing easily without retractions or accessory muscle use. Auscultation of lungs: rt lung clear, lt lung still with some minor wheezing in upper lobe, but clearly improved from last week. Percussion of chest WNL. Palpation of diaphragm without tenderness. Palpation of chest and ribs without tenderness. BP 120/70, temp 98.8. Nasal and oral mucosa moist." I would count THIS as a detailed exam of the affected body area/organ system, plus other affected/associated systems.

This kind of documentation is clearly medically necessary. Vs listing 7 systems when the complaint is for a respiratory illness. (Do you really need to examine the patient's gait and station or range of motion; or do a GU exam?)

Just my opinion.
Hope that helps.

F Tessa Bartels, CPC, CEMC