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E&M/Injection ?

  1. #1
    Question E&M/Injection ?
    Medical Coding Books
    I don't believe this note supports an E&M charge for nasal discharge and parent says when she brought child he had no URI symptoms. Please give me an opinion on the below note. thank you
    Chief Complaint(s):
    hpv#3, flu shot

    Accompanied by: Mom .
    10 year old male with mild URI symptoms. No fever. Good PO, active. Currently in grade 5 with Ms. --, enjoying football.
    Current Medication:

    Medical History:
    No Medical History.


    Surgical History:
    Denies Past Surgical History

    Denies Past Hospitalization

    Family History:
    Social History:
    Tobacco Use:
    no Smoking .

    Temp 98.5, HR 84, RR 20, Wt 141, Ht 58.5, BMI 28.96, BMI Percentile 99.03
    Past Results:
    Pediatric Male
    GENERAL: well developed, well nourished, NAD.
    SKIN: no rashes.
    HEAD: normocephalic.
    EYES: sclera w/o injection.
    EARS: TM's normal bilaterally.
    NOSE: nasal discharge.
    ORAL CAVITY: moist mucus membranes, tonsils normal.
    NECK: supple, full range of motion.
    CHEST: good air exchange bilaterally, no grunting, retractions, pink room air.
    HEART: no murmurs, regular rate and rhythm.
    ABDOMEN: soft, no hepatosplenomegaly.
    EXTREMITIES: all move well.
    NEUROLOGIC EXAM: intact.
    Physical Examination:

    URI (upper respiratory infection) - 465.9 (Primary)

    Need for prophylactic vaccination and inoculation against influenza - V04.81

    Need for HPV vaccination - V04.89

    URI (upper respiratory infection)
    Notes: Symptomatic care.
    Need for prophylactic vaccination and inoculation against influenza
    Notes: Immunization as noted.
    Need for HPV vaccination
    Notes: Immunization as noted.
    VFC - Influenza, quadrivalent, split, preservative free, 3 yrs & >, IM : 0.5 mL given by on Right Deltoid.

    VFC - HPV, types 6, 11, 16, 18 (quadrivalent) 3 dose schedule, IM : 0.5 mL (Dose No:2) given by on Right Deltoid.

    Immunization record has been reviewed and updated.

    Therapeutic Injections:
    Diagnostic Imaging:
    Lab Reports:
    Preventive Medicine:

    Disposition & Communication:
    Next Appointment:
    4 Months

    Billing Information:
    Visit Code:
    99213 Office Visit, Est Pt., Level 3. Modifiers: 25

    Procedure Codes:
    90686 VFC - Influenza, quadrivalent, split, preservative free, 3 yrs & >, IM. Modifiers: SL

    90649 VFC - HPV, types 6, 11, 16, 18 (quadrivalent) 3 dose schedule, IM. Modifiers: SL



  2. #2
    Columbia, MO
    I agree no visit, it was not requested by the parent that a visit for symptoms be performed and there is nothing to suggest an abnormal finding while administering the injections.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    thank you

  4. #4
    I agree as well

  5. Unhappy Coding scenario Help!

    Can someone please help me with this scenario, please?

    This 53 year old male with emphysema, previous lung transplant 2 years ago, was admitted with history of elevated temperature of 101 degrees with associated malaise, fatigue, and headache. The patient continued to have temperature elevations after admission. He was started on intravenous ganciclovir and intravenous impipenem. Blood and urine cultures wer basically nondiagnostic. He underwent a bronchoscopy for bronchoalveolar lavage from his left transplanted lung, which did not show any evidence of viral or bacterial pathogens. The BAL was performed by washing out the alveolar tissue in order to obtain alveolar tissue for diagnosis. Blood CMV infection. He has had a persistent cough, and microscopy confirmed the presence of pulmonary tuberculosis. The physician documentation shows the infiltrating pulmonary turberculosis and CMV are HIV related. Patient was treated with ethambutol. What codes are assigned?

    I know there should be (4) diagnosis codes, (1) V code and (1) procedure code.

    I have code 011.03, pulmonary tuberculosis, 078.5 or 042 for the CMV/HIV,
    492.8 for emphysema and 33.27 for my procedure code.

    I need the V code, which I believe it will be for the history of the elevated temperature with associated malaise, fatigue and headache, but I can not find a code for it.

    Can someone please assist me please? Thanks

  6. #6
    There is no V code for hx of fever. You can code 780.61 with underlying condition primary. Or if there is no specified condition that's causing fever code 780.60.

    Sandi B cpc cpma

  7. #7
    Actually I think the V code is regarding the lung transplant as that information is helpful because of the Emphysema DX.

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