is this 99215


Marrero, LA
Best answers
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).
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

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
Tobacco Assessment
Substance Abuse Assessment
Employment and Education Assessment
Home and Environment Assessment
Marital status: Married.

Physical Examination
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
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.

Charges (Evaluation and Management):
Return To Office (Requests):
Return to Clinic (Request) (Ordered): Return in 3 months
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
Flonase 0.05 mg/inh nasal spray (Ordered): 1 spray(s), nasal, daily, # 1 EA, 1 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
Charges (Evaluation and Management):
99215 office outpt est 40 min level 5 (Charge) (Completed): Quantity: 1


Sparta, MI
Best answers
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.


Sparta, MI
Best answers
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

Local Chapter Officer
San Antonio, TX
Best answers
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.