lburgos31
Guest
Hello eveyone, hopefully someone can help me with this.
I've been mostly experienced with Orthopedic Coding for the past 3 years and im trying to branch out. I wanted to find some training that wasnt expensive, so i purchased an E/M module from AAPC for 50 bucks. It has 20 cases to code, I believe.
I need someone to help me understand this case and rationale. I coded a 99213 and J18.8. The rationale coded 99212 and J18.9.
I thought because tests were ordered along with medication management this would constitute a 99213. Also, j18.9 is unspecified. I thought we should never code unspecified when a code for other is available?
Please let me know what you think. Thanks
Internal Medicine
Dr.Jack Kramer
Rebecca Smith
DOB: 01/xx/1927
Private Payer (Medicare rules for 65 and older)
DOS: 01/01/20XX
Office Visit, Est
Subjective: Patient was recently seen at the ER and diagnosed w/ right-sided pneumonia. She was placed on a Z-pak which she has finished. She does continue to cough. It is nonproductive. She denies any acute shortness of breath or temperature. She denies any known wheezing. She does feel like she is getting better. She denies any fever, chills, or sweats. She does have an active cough, but denies any shortness of breath or wheezing. She denies any chest pain, palpitations, syncope, or edema.
Objective: Physical Exam: W: 125lbs; H: 5'4"; T: 97.5; BP: 90/60; Pulse: 57; Respirations: 16; Pulse Ox: 96% on rm air. She is alert and responsive. She has a cough, but she is in no respiratory distress. HEART: RRR, w/o murmurs, clicks, or rubs. LUNGS: Reveal some coarse rhonchi, but no rales wheezing. She has good breath sounds. Posterior oropharynx has no redness or swelling. No tonsillar hypertrophy or exudate. No evidence of any rash.
Assessment: Resolving Pneumonia
Plan: We recommend she get a repeat chest x-ray next monday and we placed her on Tessalon Perles 200mg 1 three times a day. If she starts to run a fever again or become short of breath we want her to either present here or go to the ER. We will follow for the results of the chest x-ray.
Electronically signed by Jack Kramer, MD 1/1/20xx
I've been mostly experienced with Orthopedic Coding for the past 3 years and im trying to branch out. I wanted to find some training that wasnt expensive, so i purchased an E/M module from AAPC for 50 bucks. It has 20 cases to code, I believe.
I need someone to help me understand this case and rationale. I coded a 99213 and J18.8. The rationale coded 99212 and J18.9.
I thought because tests were ordered along with medication management this would constitute a 99213. Also, j18.9 is unspecified. I thought we should never code unspecified when a code for other is available?
Please let me know what you think. Thanks
Internal Medicine
Dr.Jack Kramer
Rebecca Smith
DOB: 01/xx/1927
Private Payer (Medicare rules for 65 and older)
DOS: 01/01/20XX
Office Visit, Est
Subjective: Patient was recently seen at the ER and diagnosed w/ right-sided pneumonia. She was placed on a Z-pak which she has finished. She does continue to cough. It is nonproductive. She denies any acute shortness of breath or temperature. She denies any known wheezing. She does feel like she is getting better. She denies any fever, chills, or sweats. She does have an active cough, but denies any shortness of breath or wheezing. She denies any chest pain, palpitations, syncope, or edema.
Objective: Physical Exam: W: 125lbs; H: 5'4"; T: 97.5; BP: 90/60; Pulse: 57; Respirations: 16; Pulse Ox: 96% on rm air. She is alert and responsive. She has a cough, but she is in no respiratory distress. HEART: RRR, w/o murmurs, clicks, or rubs. LUNGS: Reveal some coarse rhonchi, but no rales wheezing. She has good breath sounds. Posterior oropharynx has no redness or swelling. No tonsillar hypertrophy or exudate. No evidence of any rash.
Assessment: Resolving Pneumonia
Plan: We recommend she get a repeat chest x-ray next monday and we placed her on Tessalon Perles 200mg 1 three times a day. If she starts to run a fever again or become short of breath we want her to either present here or go to the ER. We will follow for the results of the chest x-ray.
Electronically signed by Jack Kramer, MD 1/1/20xx