Ortho coding/office

SHARONE

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This is my first time here so be nice. Example: My ortho doctor has a complete HPI and a moderate MDM. His exam is focused on 1 part of the body ie knee. What level of service would this be. Does ortho coding not apply to general rules for coding? I'm just wondering if I have been coding these correctly. Just need a little reassurance.

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donsqueen

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Take a look at the single system exam. You can find the 95/97 E/M guide at the medicare website. AAPC also has a link to it on the resource page. 97 guidelines have single system exams. If you print it out you can stick them in plastic sheet protectors and use dry erase markers to use them as an audit sheet.
 
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Established vs New

In addition to Amy's suggestion (excellent advice, by the way) ...

Is this an established patient? A new patient? a Consult?

You say a "complete HPI" - Do you mean a comprehensive HISTORY (not just HPI, but also chief complaint, ROS, PMFSH)?

If you have an established patient with a comprehensive history and moderate MDM you have a level 4 visit (99214).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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