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Wiki Need help is this a 99214

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dpumford

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HI! I am hoping someone can explain to me how this meets a 99214..It is an E & M example I was doing to educate myself and I need HELP!

CC: Chestpain
HPI: 58 yr old femal with intermittent, sharp chest pain over two weeks. Episodes last 10 min at a time. Pain occurs at rest.

PH: Non-smoker, no family history of Cardiovascular problems.

ROS: No shortness of breath, No reflux

Exam: Vitals: BP 120/80, P 65
Lungs: clear to auscultation
CV: normal

A/P Chest pain. ECG and stress test ordered. Follow up scheduled.

This is an example of a 99214 and I am hoping someone can give me some insite. The Hpi and Ros is fine its the rest :confused:

Thanks in Advance:)
 
That is not a good or even realistic example

I am guessing they are basing it on Hx and MDM.

History is detailed, exam is problem focused 97 and expanded problem focused 95, MDM is really crappy but I guess they are saying this is a new problem with work up (4 dx points), 1 data point for ordering testing, and moderate risk for an undiagnosed new problem which gives you moderate risk.

Hope that helps,

Laura, CPC, CPMA, CEMC
 
I agree with Laura on the exam and MDM, but I'm still not sure that this is quite a 99214. The BP and pulse are not remarkable, and the CV exam notes "normal", which by CMS Documentation guidelines, is insufficient. There should never be a notation of "normal" without further elaboration, from the system chiefly responsible for the presenting problem. (That would be considered a 'pertinent negative' finding.)

That coupled with no prescription, advice, or tentative plan of care, gives the impression that the provider doesn't view the patient's condition as 'critical' or 'acute'; the tests could have been ordered, just to rule out any cardiac anomolies. Without at least a 50/50 chance of the condition worsening before the next visit being conveyed in the record, I'd be hesitant to make this a 99214, even though it technically meets the CPT requirements. I tend to be more conservative, though.
 
Someone told me once that in order for vitals to be considered a 'system' one had to document 3 vital signs. If so then this wouldn't qualify as 99214. Any comments?
 
3 or more vitals counts as 1 bullet for constitutional under 97 guidelines. There are no bullets in 95 so as long as 1 thing is listed related to that organ system or body area then you get credit for examining that system/area.

In this example the 99214 is based on Hx and MDM so it doesn't matter what level of exam you have.

Laura, CPC ,CPMA, CEMC
 
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