Wiki Need of help with e/m

[MsMaddy]

My doctor wants to know how to make the following level 4 99214. Were having these new sheet to use, please look at this. I don't think this can be use as level 4 unless you have all other requirment for level 4.


UTI

_____ Days Temp___F

Recurrent UTI's Y N CVAT Y N

Fever/chilsl Y N Suprapubic tenderness Y N

Nausea/vomiting Y N Flan pain Y N

Suprapubic Pain Y N U/A WBC Y N

Frequency y N U/A RBC Y N

Hestiancy Y N U/A Bacteria Y N

Burning/Itching Y N Insufficent urine for U/A Y N

Blood Y N Insufficient urine for C/S Y N

Meds Tried Y N _________


Cystitis dysuria Hematuria Pyelonephritis Recurrent UTI

Amoxicillin Augmentint Avelox Bactrim Cipro Doxycycline Floxin

Fosfomycin Keflex Levaquin Macrodantin Pyriduim

____mg QD BID TID QID x____ days #____ C&S RTO_____

Rocephin __mg IM now / R L UOQ W W/O Xylocaine Fluids Acet/lbu CBC

Prophylaxis: Post-coital Daily Med:__ mg__ RTW_____


HOW CAN YOU MAKE THIS A LEVEL 4, WHAT ELSE NEEDS TO BE ADDED TO MAKE IT A LEVEL 4? HELP!

THANK YOU IN ADVANCE

MsMADDY

 

[FTessaBartels]

Not sure I understand

I'm not sure I understand what this is. Is it some sort of template you use?

To get a 99214 you need two of the following three key elements
DETAILED history (Chief complaint / 4 elements of HPI / 2-9 ROS / 1 of PMFSH)
DETAILED exam - 1995 guidelines: extended exam of affected body area/organ system, plus other related systems
1997 guidelines: 2 elements from each of 6 areas/systems -OR- at least 12 elements in 2 or more areas/systems
MODERATE MDM - Moderate risk (Antibiotic prescription qualifies) PLUS either 3 or more problem points -OR- 3 or more data points.

It would be helpful if your template was organized for these three key areas. I had to really hunt and peck to get the info I needed, but I was able to get 4 elements of HPI (location inferred from complaint, duration in days, assoc sign for fever, Modifying factors for meds tried. (This, of course, assumes that ALL these boxes are filled in.) I would use the recurrent UTI question as past medical history; I would recommend adding a question about allergies to meds as well. I would use the rest of the symptoms/signs you query about as ROS (GI for nausea/vomiting, GU for the rest)

I think you have data points for U/A (1 point regardless of how many ways you order this) Might the physician also be ordering US or other diagnostics for recurrent UTI?

I can't tell from your organization if the references to flank pain and suprapubic tenderness are as a result of exam or if they are ROS questions to patient. Even if they are exam, you don't get a detailed exam (even with 1995 guidelines); at best you get an expanded problem focused exam if you count the actual temp taken in office as constitutional.

You have risk covered, but it would be helpful if you had a qualifier on the Dx (other than the "recurrent UTI") ... Is this a stable or improved problem? A worsening problem? (I'm thinking about the patient who returns to see physician for no improvement on antibiotics.)

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[MsMaddy]

I'm not sure I understand what this is. Is it some sort of template you use?

To get a 99214 you need two of the following three key elements
DETAILED history (Chief complaint / 4 elements of HPI / 2-9 ROS / 1 of PMFSH)
DETAILED exam - 1995 guidelines: extended exam of affected body area/organ system, plus other related systems
1997 guidelines: 2 elements from each of 6 areas/systems -OR- at least 12 elements in 2 or more areas/systems
MODERATE MDM - Moderate risk (Antibiotic prescription qualifies) PLUS either 3 or more problem points -OR- 3 or more data points.

It would be helpful if your template was organized for these three key areas. I had to really hunt and peck to get the info I needed, but I was able to get 4 elements of HPI (location inferred from complaint, duration in days, assoc sign for fever, Modifying factors for meds tried. (This, of course, assumes that ALL these boxes are filled in.) I would use the recurrent UTI question as past medical history; I would recommend adding a question about allergies to meds as well. I would use the rest of the symptoms/signs you query about as ROS (GI for nausea/vomiting, GU for the rest)

I think you have data points for U/A (1 point regardless of how many ways you order this) Might the physician also be ordering US or other diagnostics for recurrent UTI?

I can't tell from your organization if the references to flank pain and suprapubic tenderness are as a result of exam or if they are ROS questions to patient. Even if they are exam, you don't get a detailed exam (even with 1995 guidelines); at best you get an expanded problem focused exam if you count the actual temp taken in office as constitutional.

You have risk covered, but it would be helpful if you had a qualifier on the Dx (other than the "recurrent UTI") ... Is this a stable or improved problem? A worsening problem? (I'm thinking about the patient who returns to see physician for no improvement on antibiotics.)

Hope that helps.

F Tessa Bartels, CPC, CEMC

So how would code this ? To me level would be too high, a level 2 maybe ?

Thanks Again
MsMaddy

 

[FTessaBartels]

You have NOTHING

As your example sits you have NOTHING codable except 99211 (because you have a chief complaint ... or at least I'm assuming UTI is the complaint)

What I see is a sort of template with questions the provider is supposedly asking and recording the answers. With no answers you have nothing beyond a level 1 established patient visit. If this is a new patient you have no service level at all.

F Tessa Bartels, CPC, CEMC

 

[MsMaddy]

As your example sits you have NOTHING codable except 99211 (because you have a chief complaint ... or at least I'm assuming UTI is the complaint)

What I see is a sort of template with questions the provider is supposedly asking and recording the answers. With no answers you have nothing beyond a level 1 established patient visit. If this is a new patient you have no service level at all.

F Tessa Bartels, CPC, CEMC

Thank you so much for your help.
MsMaddy