Wiki Need some help!

[TMB1965]

This is my first time coding E&M, and I was told if the MDM and the Examination don't match up with the CC you can't code the higher code, but I thought it went by 2 out of the 3 components, and you take the lower one off that determines the level of service. Can someone clarify this for me?

 

[TMB1965]

Here is an example where the provider is coding a 99214, and its a new patient, so I know this is wrong, and I think it should be a 99203. Can someone give me their opinion on what they think. Thank you.

CC:
Referred for Lymph node biopsy

HPI:
Patient had noticed enlargement of lymph nodes in the neck and had CT scan done that showed generalized lymph nodes in chest axilla and groins. He was seen by provider ? and underwent bone marrow biopsy and was advised lymph node biopsy.
He denies pain, fever. weight loss.
No family h/o malignancy.


ALLERGIES:
No Known Allergies Confirmed -
Allergy list reviewed. updated

CURRENT MEDICATIONS:
Medications List Reviewed

Medication list reviewed. updated

PAST MEDICAL HISTORY:
Past Medical History Reviewed updated
The patient has a past medical history of Hypertension, Diabetes Mellitus type 2, Hyperlipidemia.
Other past medical history includes chronic lymphocytic leukemia OF B CELL TYPE.

No recent change in medical history. updated

SURGICAL HISTORY:
Previous surgery includes bilateral hip replacement X 2


SOCIAL HISTORY:
Smoking Status: Never smoker

Tobacco User: No
No counseling on tobacco cessation
Rx therapy for tobacco cessation
Did not discuss Smoking/Tobacco Use Cessation Strategies

Alcohol use: Non-Drinker

Social History Reviewed updated

FAMILY HISTORY:
Family History Reviewed updated

PREVENTIVE CARE:
Colonoscopy:

REVIEW OF SYSTEMS:

General:
No constitutional symptoms.
No fatigue, no fever, no chills, no weight loss.
Neck:
Small lymph nodes both posterior neck..
Cardiovascular:
no cardiovascular symptoms.
Respiratory:
no respiratory symptoms.
Gastrointestinal:
No GI symptoms.
Genitourinary:
no gu symptoms.
Musculoskeletal:
no musculoskeletal symptoms.
Hip pain.
Neurologic
no neurologic symptoms.
Psychologic:
no psych symptoms.

VITAL SIGNS:
Were taken

PHYSICAL EXAMINATION:
General:
alert, oriented to time, place and person, well nourished, in no acute distress.
Neck:
Bilateral small posterior triangle nodes. Non tender.
Lymphatics:
Bilateral axillary and groin palpable nodes. All are soft non tender.


IMAGING STUDIES:
CT Scan:
Generalized lymphadenopathy

ASSESSMENT:
GENERALIZED LYMPHADENOPATHY. R/O MALIGNANT LYMPHOMA.
DIABETES.
HYPERTENSION


PLAN:
Excision biopsy left axillary lymph node.
Discussed with patient.

 

[penguins11]

for a new patient its 3 out of 3 components so the exam counts. There doesn't appear to be much of an exam there. The highest im getting is 99202.

 

[bigredcag]

I come out with a 99202 as i do not see 4 HPI the exam & MDM meets a 99203.
per AAPC
HPI: need 4 (only got 2)
ROS: need 2 (good)
PFSH: need 2 (good)
exam: 1995 guidelines
2+ body/organ systems (brief statement)=EXPANDED PROBLEM FOCUSED
Constitutional and lymphatic organ systems (which multiple lymphs were examined)
MDM: Low
due to the HPI lacking 4 elements I would only give it the 99202 based on the 3 out of 3 requirements.

 

[bedforak1]

I am scoring a 99202 as well. Hope that helps!