Hep C Patient/E/M Level

cnramsey

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My provider states he was told he can charge a 99215 due to to the monitoring of potentially lethally toxic chemotherapeutic agents. Does the documentation below support a 99215?

Referring Provider:
Primary Provider:
CC: f/u Hep C.

History of Present Illness:
Patient presents today for Hep C f/u. He/she has now completed 24 weeks of tx -- his/her viral load was negative this week. His/her CBC shows mild anemia, mild thrombocytopenia and mild depressed WBC. LFT's continue to improve.

Past Medical History:
chronic right hip pain
HTN
hepatitis C
-Genotype 3a
- s/p 24 wks tx with IFN + Ribavirin
- undectable viral load at 24 weeks
- need to recheck in 6 months

Past Surgical History:
Reviewed history from 03/10/2009 and no changes required:
tib fib fx repaired
right hip surgery
repairs from tendon lac to right wrist

Family History:
Reviewed history from 11/03/2010 and no changes required:
dad and grandfather died of stomach cancer

Social History:
Reviewed history from 03/10/2009 and no changes required:
smoker

Risk Factors:

Tobacco use: quit
Year quit: 2011
Drug use: prefer to discuss with physician
HIV high-risk behavior: no
Caffeine use: Drinks coffee, soft drinks times per day.
Alcohol use: yes
Type: Drinks beer, liquor 1 time per month having 3-5 per occasion. Rarely has more than five drinks per occasion.
Exercise: yes
Times per week: occasionally /wk
Type: swimming, walking
Seatbelt use: 100 %

Review of Systems

General
Complains of fatigue and malaise.

GI
Denies nausea, vomiting, abdominal pain, abdominal bloating, and change in bowel habits.

Vital Signs:

Patient Profile:
Height: 72 inches (182.88 cm)
Weight: 213.2 pounds
BMI: 29.02
BSA: 2.19
Temp: 97.3 degrees F tympanic
Pulse rate: 68 / minute
Pulse rhythm: regular
BP sitting: 120 / 76 (left arm)
Cuff size: regular

Vitals Entered By:


Physical Exam

General:
well developed, well nourished, in no acute distress.


Test Management:

Tests Reviewed:
BMP:
BUN: 16 (05/31/2011)
Creatinine: 0.9 (05/31/2011)
Sodium: 139 (05/31/2011)
Potassium: 4.5 (05/31/2011)
Chloride: 105 (05/31/2011)
CALCIUM: 9.4 (05/31/2011)
ANIONGAP: 11 (05/31/2011)
CO2 Total: 27.2 (05/31/2011)
GLUCOSE SER: 101 (05/31/2011)
LFT's:
SGOT (AST): 59 (08/03/2011)
SGPT (ALT): 74 (08/03/2011)
PROTEIN, TOT: 7.3 (08/03/2011)
ALBUMIN: 3.8 (08/03/2011)
ALK PHOS: 61 (08/03/2011)
BILI TOTAL: 0.60 (08/03/2011)
BILI DIRECT: 0.20 (08/03/2011)
*Anemia view:
HGB: 10.7 (08/03/2011)
HCT: 33.4 (08/03/2011)
MCV: 113.2 (08/03/2011)
MCH: 36.3 (08/03/2011)
MCHC: 32.0 G/DL (08/03/2011)
Platelets: 74 (08/03/2011)

Impression & Recommendations:

Problem # 1: HEPATITIS C, CHRONIC VIRAL (ICD-070.54)
Negative viral load at 24 weeks.

Plan to recheck CBC in 6 weeks; anticipate resolution of labs to pre-treatment values.

Recheck viral load in 6 months. Flag made.

Pt visit today was primarily counseling, coordination and monitoring of potentially lethally toxic chemotherapeutic agents.

Orders:
Hemogram (CBC no diff) (HGMP)
 

jackson7591

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Counseling

Once the provider states that the primary reason for the visit is counseling, you can theoreticaly bill a 99215, so long as the time spent counseling matches the time typically spent for a 99215.

However, then the burden of documentation is to include the time spent counseling the pt and a detailed note of the topics/issues addressed and the medical necessity of the counseling. Both seem to be lacking in the documentation.

If your provider wishes to document monitoring of potentially toxic medications there are medical policies acknowledging instances where this is medically necessary.

Had documentation indicated that the provider reviewed and considered various lab values, presence or absence of indicators of toxicity or complications or even concerns affecting MDM regarding pt response/tolerance to such medications, the answer might be yes. However his/her documentation doesnt include any documentation that drug toxicity was a large part of his/her medical decision making or even the purpose of the visit. There are lab values listed, but no reference to them regarding the provider's use of their values to monitor or continue or change the treatment plan.

Concerns regarding toxic drug effects may well have been the reason for the office visit and would certainly be medically appropriate. But while that may have been the case, the documentation does not clearly or adequately reflect that. Dont mean to sound harsh. I'm always reminding my providers, clearly state your concerns and reasons for continueing or changing a treatment plan in writing. If its not in written, i cant see it.
 
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