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daniel

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I'm new to this E/M coding. Starting to get my feet wet, working for this Family Practice in O.C. I'm doing the internal audits for this practice. Looking to gain money for them, versus trying to strike down every code I see with not enough doc.
With this said my QUESTION.

Say we have a patient with a New problem, of just Pharyngitis or Cough with URI or Bronchitis. And we do a exam of 5 to 7 organ systems. With a prescrition of Antibiotic issued.

What level is this for an establish visit.
I want to give this a level 4. It seems that the two out of three are met. But I'm told by some, that Pyharyngitis or just a cough with URI is to weak of an diagnosis.

Need some opions out there.

Thank You.
 
Without seeing the documentation, I could only guess, but I would say that the complexity of the presenting problem would only merit a medical necessity of a level 3.
 
Level 4 vs 3

For us, the decision making for this type of visit is no question a level 4. Its a new problem and moderate complexity risk due to the rx. According to the AMA coding guidelines in this case with the exam being a level 4 you can code a 99214. I get nervous when its a Medicare patient although they say that the decision making should drive the code. I struggle with this one too just because it appears to be such a straight forward visit. If the patient has any co-morbitities, this will help support the level 4. Generally, we code these a level 3 if there are absolutely no other issues being addressed.

I will be watching this thread closely to see what others are doing.
 
I guess my "opinion" would be based on the actual diagnosis. If it is just Pharyngitis, 99213; but if it is Bronchitis, why not 99214? Bronchitis is a higher risk infection than a simple Pharyngitis.
Lisa
 
Thanks to all you, who let there thoughts be known. Glad to see I'm not the only one on the fence pertaining to this question.
 
I'm also a new coding auditor for EM. I've struggled and fought with our doctors over this exact same scenario. Even though it is a new problem, new medicine, documentation is there, I would code a cough or URI as a 99213. The Medical Decision making is truly what I look at. If the patient has comorbidities and other problems that are addressed at the same time, I would bump up the code, but a cough or URI is low risk to the patient.
 
Even with a dx of bronchitis, without any comorbidities I would only code this scenario as a 3rd level est pt or 2nd level new pt. Coming from the urgent care setting, I see a lot of bronchitis and my doctors think that a dx of bronchitis or pneumonia is automatically a 4th level visit, but they don't provide enough documentation. In these situations, I look at comorbidities and tests done to assess the patient's condition.
 
Billie

If the doctor documents the EM as a 99214 or 99215 if we get a denial from our electronic filing that states documentation does not support this code can we change it?
 
daniel said:
I'm new to this E/M coding. Starting to get my feet wet, working for this Family Practice in O.C. I'm doing the internal audits for this practice. Looking to gain money for them, versus trying to strike down every code I see with not enough doc.
With this said my QUESTION.

Say we have a patient with a New problem, of just Pharyngitis or Cough with URI or Bronchitis. And we do a exam of 5 to 7 organ systems. With a prescrition of Antibiotic issued.

What level is this for an establish visit.
I want to give this a level 4. It seems that the two out of three are met. But I'm told by some, that Pyharyngitis or just a cough with URI is to weak of an diagnosis.

Need some opions out there.

Thank You.
Click to expand...

hi daniel -
I'd go with a level 4 est E/M. It is what it is - it supports a level 4 even if the History component falls short. The Exam and MDM are there. In all my years of coding, I've actually never heard that pharyngitis or cough were not "strong" enough dx's for coding a "high" level E/M.! (I guess I learn something new everyday). That being said, I still say, it is what it is and if documentation supports a level 4 E/M I don't see any reason not to code it out as such. I will say however, that most sore throats, even strept visits that I've coded are usually at a level 3. But I wouldn't have a problem coding a level 4 if documentation supported it.
{that's my opinion on the posted matter}
 
I find it a little "disconcerting" that you are doing internal auditing and then in the same breath stating that "I have heard from some that pharyngitis or cough with URI are too weak of a diagnosis......" That statement makes no sense to me. As the previous post suggested, the documentation either meets the criteria for a level 4 or it doesn't.
 
Nature of Presenting Problem

Check 2008 CPT Professional Edition, begining on page 3 under "Nature of Presenting Problem."
I would characterize pharyngitis as "self-limited or minor"

Now go to page 5-6 under "Instructions for Selecting a Level of E/M Service" and you'll note on page 6 under "Review the Level of E/M Service Descriptors and Examples in the Selected Category or Subcategory," the last paragraph in this section reads:
"The nature of the presenting problem and time are provided in some levels to assist the physician in determining the appropriate level of E/M service."

Now go to page 10 and find the descriptions of Established Patient Office Visits ...
Under 99212 it states: "Usually the presenting problem(s) are self limited or minor."
Under 99214 it states: "Usually, the presenting problems(S) are of moderate to high severity."

This is why you might be told that Pharyngitis is a "weak diagnosis" for a level 4 visit, even when the documentation meets all the bullet points for that level.

F Tessa Bartels, CPC, CPC-E/M
 
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EM Level

I agree. Code the documentation. Use the E/M guidelines. It is black and white. CPT states specifically what is required to determine the level of service. Any rx makes the MDM=moderate. It is what management risk the physician is performing. We as coders cannot determine that pharyngitis is a "weak" diagnosis, the physician's level of risk for his medical decision making is considered moderate for non-parenteral controlled substances.
 
We have a place called Medisync come in to educate our physicians on coding. They are telling the physicians that something like pharyngitis would always come out to a 99214 when audited, if a prescription is given. They say that the exam that would have to be done, along with the presciption that is ordered (which is moderate decision making) will always come out to a level 4 visit. If there are no other conditions present that is putting the patient at risk, or no presciption is given then a level 3 would be appropriate.
 
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