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Is this a 99214 or 99215???????


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I am doing an internal audit and wondering if this is a 99214 or 99215
Comes in today for a recheck. He is unaccompanied today but does have a list from his cardiologist whom recently stopped his Amiodarone but increased his Torsemide to 3 tablets Monday, Wednesday, & Friday and one every other day in that he is noting increased bruising and bleeding.
Patient would indicte that his blood sugars have been runnign fine at home but dit not bring hisblood sugar readings. He still feels very foggy in the head and tired. He has not noted a marked change in that even with his morning blood sugarsback to normal range. He is short of breath with limited activity. I don't have correspondence back from Dr. Doe whom saw him last Thr4usday, making these changes.
In addtion he did have a sleep study but apparently this didn't go so well. He would indicated that this was a waste of time, I don't see the report right now, all be it, I'll try and get this figured out. Our question is certainly in regard whether sleep apnea could play a role, otherwise he was simply ahving some hypoxia throught the night that could be contributing. It doesn't sound like, according to patient, they got much of a study.
Patient does look sharper today. He answers questions appropriately. Maintains good eye contact.
BP: 102/60; Pulse: 60, WT: 151.4
INTEG: He has trace edema at this time.
HEENT: I see no focal changes. TMs,nasal passage and oropharynx is clear.
NECK: supple. does not have JVD> I note no mass or thyromegaly. Carotids do appear adequate.
LUNGS: I note no crackles, rhonchi or wheezes
HEART: Actually shows pretty regular rate and rhythm today, I don't note ectopy
ABD: benign
EXTREM: no acute chagnes
NEURO: Awake, alert & appropriate today. No focual or neurologic changes on exam.
1. CHF, clinically improved
2. CAD, staus post MI
3. Renal insufficiency
4. Dyspnea, multi-factorial
5.Chronic atrial fib, dc'd on Amiodarone
6. suspected sleep apnea
7. bipolar disease
8. DM II with recent hypoglycemia, resolved
I'll followup on his sleep study see if we can find results. His wife voices as to whether he might be a candidate overnight O2. I would need to see what his saturations specifically showed. It would be my hope that he starts feeling gradually a little bit better off of the Amiodarone. We/ll recheck him again in a month.
A 99215 MDM states 1 or more chronic conditions with severe exacerbation, or illness that poses threat to bodily function or threat to life, abrupt change in neurologic status. I'm thinking the patient was stable when he came in for the visit even though he has several condtions and not sure about a 99215. Please advise. Thanks so much.
Any help would be appreciated.


Baton Rouge
Best answers
Because the physician stated that the patient has improved and that he really didn't do anything, I would code this as 99214.


Boston, MA
Best answers
Hi -
First of all I'd like to ask what the chief complaint for this specific visit is? Without it, you shouldn't bill at all.
Second, the HPI requirement don't seem to be met even for 99214.
Then the note contradicts itself: the patient "is unaccompanied today", however "his wife voices as to..." Was the wife there or not?