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Wiki History with 2 presenting problems

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msingh23

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I will like to know if it is possible using 1997 DG OR 1995 DG more so DG 1997 on a patient first visit with two or more Different problem and Dr address both problems it qualifies for Comprehensive history, but not a E&M New pt level 4 also must meet the other requirments as Exam Comprehensive and MDM Moderate for E&M new pt L4
Thanks
msingh23
 
Will you repost your question? I don't understand what your asking. I have tried breaking up the sentences, but I can't figure out the question or what your asking. yes, a 99204 requires the comp history, comp exam, and MDM moderate complexity.

What are you asking?
 
Thanks..
The question is:
New Visit with two or more Different problem and Dr address both problems does it qualifies for Comprehensive history?
Thanks
 
Only if the documentation is there, a patient can have numerous problems but with inadequate documentation it still may not have a comprehensive history or exam. The note speaks for the level.
 
Thank you , Thank you.
I try saying that but Dr. insist on Dx... so I though ok maybe I am somethig off..thanks for your respond.
 
A diagnosis does not drive E&M coding. Documentation following the guidelines drives the level of coding You can use 95 guidelines or 97 but cannot mix and match on a single claim. You are allowed to use whichever set of guidelines is most beneficial to the provider.
 
Does your doctor realize that coding E/M is based on a very specific counting of "points"? In the history section of E/M, the number of points depends on the actual number of "questions" relevant to the diagnosis that the patient answered for ROS, PSFS, and (especially) HPI.

I can send you a copy of my E/M worksheet if you'd like. It's based on the 1997 guidelines. Just click on my profile and choose the "contact info" tab to ask me for it.
 
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