over coding?


Melbourne, Florida
Best answers
My doctor is an Internist.
The patient's medical history is remarkable for ASCVD/CAD, dyslipidemia and hypertension.

The Cardiologist treated/wrote rx's for the patient for all of the above on 10/19/10.
pt is to follow up in 6 months as this note was forwarded and reviewed by us (the Internist)

Today (01/20/11) the patient is followed by the internist for an O.V. to review the labs ( we ordered months ago) and RX Refill. , we performed an exam ROS x 9 .

The exam showed all systems negative for complaints or symptoms.

The assessment sts as above.

The plan .. we wrote rx's for CRestor/ Tricor.

Is it ok for us to bill dx: ASCVD/CAD, dyslipidemia and hypertension?

Scenerio 2: If the patient has foot pain, would we bill just for the foot pain?

Sorry for being complicated ...
Thanks for reading.. any input is helpful ..

Sandy Stevens

Nashville, Tennessee
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If the intent of the visit (in your office) was a f/u on the 3 chronic illnesses (though also followed by cariologist), then the Hx obtained and Exam performed should be commensurate with the level of MDM for those conditions, and the A/P should include the status of those 3 chronic illnesses (e.g., "has been stable **comes from review of last lab/test values and cardio records**; continue Rx regimen, refills today; CBC, CMP, lipids ordered to assess effectiveness of current tx; f/u in 3mos"), and should be reported *** If, in the same encounter, the patient also c/o foot pain, and Hx and Exam was needed in order to assess the symptoms, then the foot pain would also be included in the A/P and reported (symptom or definitive diagnosis if determined during the encounter) -->>The chronic illnesses would reported, followed by the foot pain ***** If the intent of the encounter was for the foot pain only, but during that encounter the physician also assesses the existing chronic conditions, (as described above), then the first-listed dx would be the foot pain, followed by the chronic conditions. *** In both clinical scenarios the level of E/M service should support 99214, assuming documentation is adequate, according to Documentation Guidelines. *** does this help?


Lubbock, TX
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I agree with Sandra; it seems like you've got enough HPI to support a higher level code, as long as the exam and MDM elements are there, and the foot problem was actually addressed. If it was just mentioned in the history, but not examined, assessed, or treated, then it doesn't count toward your code selection. Also, the status of the three chronic conditions must be stated in the history of present illness in order to receive credit for them. Listing them as diagnoses at the bottom of the chart and refilling prescriptions, without further elaboration, doesn't qualify as giving the status of a chronic condition when counting HPI. If either of those are the case, the best you can hope for is 99213. Hope that helps!;)