is this 99215

perkins05

Expert
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297
Location
New Orleans
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Does this note code to 99215? All responses are appreciated..

Earache *

Associated Diagnoses: HTN (Hypertension), Benign; Ear Problems; Rhinitis, allergic; Obesity; Vertigo


Chief Complaint
left ear clogged up leading to dizziness

History of Present Illness
The patient presents with 35 y/o male here for "clogging" left ear with dizziness and tinnitus. States h/o vertigo. Denies ear pain.

Also elevated bp. Had recent labs at job in November with glucose, cholesterol which he states were normal. Had elevated bp at work and on 2 occasions here. . Exacerbating factors consist of none. Relieving factors consist of none. Associated symptoms consist of none.

Review of Systems
Constitutional: No fatigue.
Eye: No recent visual problem, No blurring, No double vision, No visual disturbances.
Respiratory: No shortness of breath.
Cardiovascular: No chest pain, No palpitations, No peripheral edema, No syncope.
Gastrointestinal: No nausea, No vomiting, No abdominal pain.
Genitourinary: No dysuria.
Integumentary: No other significant skin complaints.
Neurologic: No headache.
ROS reviewed as documented in chart

Health Status

Allergies: .
Allergic Reactions (Selected)
No known allergies

Medications: (Selected).
Prescriptions
Ordered
Augmentin 875 mg oral tablet: 1 tab(s), PO, q12hr, # 20 tab(s), 0 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
Medrol Dosepak 4 mg oral tablet: 1 packet(s), PO, Once, Instructions: as directed on package labeling, # 21 tab(s), 0 Refill(s), Type: Soft Stop, Pharmacy: CVS/pharmacy# 4752
Ventolin 90 mcg/inh inhalation aerosol: 2 puff(s), INH, QID, PRN: for wheezing, # 1 EA, 0 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752

Problem list: .
All Problems (Selected)
Morbid Obesity / ICD-9-CM 278.01 / Confirmed

Histories
Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
No family history items have been selected or recorded.
Procedure history: .
kidney stones in 1900.
Social History: .
Alcohol Assessment
Never
Tobacco Assessment
Never
Substance Abuse Assessment
Never
Employment and Education Assessment
Employed
Home and Environment Assessment
Marital status: Married.

Physical Examination
VS/Measurements
Vital Signs
Temperature Oral 98.2 DegF
Peripheral Pulse Rate 76 bpm
Pulse Site Radial artery
Respiratory Rate 20 br/min
Systolic Blood Pressure 146 mmHg HI
Diastolic Blood Pressure 100 mmHg HI
Mean Arterial Pressure 115 mmHg
BP Site Left arm
Oxygen Saturation 98 %
, Measurements from flowsheet : Measurements
Height 68.00 in
Weight 431.20 lb
BSA 3.06 m2
Body Mass Index 65.56 kg/m2

General: Alert and oriented, No acute distress.
Eye: Vision unchanged.
HENT: Normocephalic, Tympanic membranes are clear, Oral mucosa is moist, No pharyngeal erythema, No sinus tenderness, swollen, boggy nasal mucosa.
Neck: Supple, No carotid bruit, No jugular venous distention, No thyromegaly.
Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal.
Cardiovascular: Normal rate, Regular rhythm, No murmur, No gallop, Normal peripheral perfusion, No edema.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.
Integumentary: Warm, Dry, Pink, No rash.
Neurologic: Alert, Oriented.
Psychiatric: Appropriate mood & affect.

Impression and Plan
Diagnosis
HTN (Hypertension), Benign (ICD9 401.1).
Rhinitis, allergic (ICD9 477.9).
Obesity (ICD9 278.00).
Vertigo (ICD9 780.4).
Ear Problems (ICD9 V41.3).

Patient Instructions: Counseled: Patient, Regarding diagnosis, Regarding treatment, Regarding medications, Diet, Activity, Verbalized understanding.
Summary: Ear problems likely sec. to allergy or vertigo-antivert prn and nasonex. referral to surgery for weight loss consultation. pt to bring copy of recent labs. referral for ophthalmology. spent 40 minutes with pt.
Orders


Charges (Evaluation and Management):
Return To Office (Requests):
Return to Clinic (Request) (Ordered): Return in 3 months
Orders.
Pharmacy:
Bystolic 5 mg oral tablet (Ordered): 1 tab(s) ( 5 mg ), po, daily, # 21 tab(s), 0 Refill(s), Type: Maintenance, samples given to patient (Rx)
Return To Office (Requests):
Return to Clinic (Request) (Ordered): Return in 2 weeks
Orders.
Pharmacy:
Flonase 0.05 mg/inh nasal spray (Ordered): 1 spray(s), nasal, daily, # 1 EA, 1 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
Orders.
Charges (Evaluation and Management):
99215 office outpt est 40 min level 5 (Charge) (Completed): Quantity: 1
 

ksd

Networker
Messages
73
Location
Sparta, MI
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I agree with Cheermom. I would give this a 99213. No tests were given and the MDM was just not that high. Giving it the distinction of a 99215 would be putting it on the same level as a patient coming in with respiratory distress receiving a chest x-ray and several breathing treatments. Somehow just because the Dr. spent 40 minutes talking with the patient does not seem to warrant bumping up 2 E/M levels.
 

ksd

Networker
Messages
73
Location
Sparta, MI
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If you show him the description of the code 99215 he can see where it will state of course
-Comprehensive history (4 elements)
-Comprehensice Examination (8 elements)
-MDM high complexity

Then comes the description I believe your doctor is getting his 40 minutes from where the AAPC states "Usually, the presenting problem(s) are of moderate to high secerity. Physicians TYPICALLY spend 40 minutes face-to-face with the patient and/or family"

I usually code ER visits and we often see a patient spend no more than 30 minutes with physician and it be a level 5 (without admission). Also patient would spend up to about an hour with patient and it would be a level 3. Appendix C gives several clinical examples of E & M levels. Incidentally, while scanning the examples, I do not see one where time was mentioned in the example.
 

Evelyn Kim

Guru
Local Chapter Officer
Messages
201
Location
San Antonio, TX
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I agree, just because the provider spent 40 minutes with the patient does not justify billing a level 5. There is no documentation of MDM of high complexity, there is no documentation on consuling or coordination of care that would justify the 40 minutes.
 
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