SueTeal
Contributor
Our Practice is doing an extensive internal audit on E/M coding. A primary care provider documented a detailed history, detailed exam, and low medical decision making on a patient with a cold which is actually resolving. The patient is in their 30's. I realize 2 of the 3 key components meet and support the 99214, but isn't this where nature of presenting illness (the contributing factor) comes into play? I don't think this patient is at a moderate risk of mortality if they left the office untreated. The risk is low or even lower. That's the thought process I use. I'm having a dispute with another Coder on the Team and would like some help with this interpretation. The patient does not have history of Asthma or COPD or any other comorbidities that might influence a higher level of complexity.