Results 1 to 7 of 7

Level?

  1. #1
    Unhappy Level?
    Exam Training Packages
    HPI - 34 yo male sent to ER after an intentional drug overdose. Pt reports he wanted to kill himself - "tired of living this life", took a handful of pills - Klonopin, Seroquel, Invega, stool softener and Tegretol. Pt reports he took all those pills over the past few hrs and had attempts in the past. Sister called EMS. Presently he denies CP, SOB, N/V or abd pain.

    ROS - Head, Nose, Pharynx, CV, RESP, GI, Musculo, and Neuro

    PMH - schizoaffective disorder, multiple suicide attempts.
    SH/FH - Disabled, drug use, mother deceased, sister alive

    PE - 11 systems examined.
    Labs, EKGs - done

    Pt admitted to ICU with IV saline. Will consult psychiatrist for further evaluation

    What would be the level for this? I'm getting a level 3 due to the pt's chronic mental illness.

  2. #2
    Default
    CC: Drug overdose
    HPI:
    Duration-past few hours
    A/s-attempts in past
    ROS- 6 (head doesn't count, it's considered a body area)
    PFSH- 3/3
    History: Expanded Problem Focused

    Exam: you state 11 systems examined. This would be comprehensive based on 95 DG's.

    MDM:
    New prob (I'm assuming new problem) w/ work up.. 4 points
    Labs 1 point
    EKG 1 point
    Risk: IV fluids and/or chronic illness w/ exacerbation...moderate risk
    MDM: Moderate

    The documentation states patient was admitted. By your physician? Probably so. The documentation doesn't justify even the lowest level admission, 99221.(This requires comprehensive/detailed history, comprehensive exam, medical decision making of low/straightforward) The only difference between the higher two levels is the MDM (moderate, high, respectively..) and of course the time is different.

    I, personally, would educate your physician. (Primarily in documenting a complete history..hit atleast 4 HPI elements, complete 10 point ROS..) Maybe even review a few more of his/her admissions, show them what the requirements are and what their documentation must consist of.

    The note you have posted is not billable unless you take the route of billing an unlisted E/M code, 99499, sending in the documentation, and letting the payer decide how much the reimbursement is.


    Good luck!
    Last edited by ARCPC9491; 03-24-2009 at 12:34 PM. Reason: made a mistake :)

  3. #3
    Default
    ALL levels of admission require both comprehensive history and exam. The only difference between the 3 levels is the MDM (low, moderate, high, respectively..) and of course the time is different.

    99221 is Detailed or Comprehensive history and exam, they don't have to be comprehensive.

    I think this is a detailed HPI so it would put the history level up to detailed.

    HPI - 34 yo male sent to ER after an intentional drug overdose(chief complaint). Pt reports he wanted to kill himself (context)- "tired of living this life" (severity), took a handful of pills - Klonopin, Seroquel, Invega, stool softener and Tegretol (modifying factor). Pt reports he took all those pills over the past few hrs (timing) and had attempts in the past (possibly duration). Sister called EMS. Presently he denies CP, SOB, N/V or abd pain.

    Just my take on it, whether or not you agree with the HPI elements at least be aware you can have an admit with a detailed history and exam.

    Laura, CPC

  4. #4
    Default
    Thanks for catching that! I always do that with 99221 & I don't know why! I corrected my post...

  5. #5
    Default
    HPI - 34 yo male sent to ER after an intentional drug overdose(chief complaint). Pt reports he wanted to kill himself (context)To me, context is more of, where and what was the patient doing?- "tired of living this life" (severity)this is tough because severity is like on a pain scale 1-10, but on the flip side, I guess you could argue his life was so bad it got severe enough he wanted to take his life. took a handful of pills - Klonopin, Seroquel, Invega, stool softener and Tegretol (modifying factor)The documentation doesn't say what these drugs did to him, he obviously didn't die, he has no positive ROS listed, so really what effect did it have? If he stated patient lethargic, vitals low, heart stopped, or what have you... I think I would count it then as modifying factor Pt reports he took all those pills over the past few hrs (timing)I would rather this be duration, timing is more specific like intermittent, constant, etc. and had attempts in the past (possibly duration)I would use this as associated signs/symptoms demonstrating the destructiveness this disease has on him.. Sister called EMS. Presently he denies CP, SOB, N/V or abd pain.

    Just my thoughts....

  6. #6
    Default Thanks
    It was coded as a 99222. I had a 99221.

    Thanks everyone!

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Just the HPI
    I just love E/M coding because it's so open to interpretation (slightly sarcastic tone).

    You don't say if you have a chief complaint stated independently of the HPI. So I'm counting "drug overdose" as the CC.

    For the HPI, I'd consider:
    Quality: intentional, tired of living this life
    Context: took a handful of pills
    Severity: the listing of all the pills
    Duration: over past few hours
    Modifying factors: attempts in past; sister called EMS
    Assoc signs: denies CP, SOB, N/V or abd pain

    Adding up the ROS and PMFSH, I'd get a detailed history

    So you have a 99221.

    Good idea to educate your physician that without 10+ ROS and a 3/3 PMFSH you can never get above a 99221.

    Just my thoughts ...

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Replies: 1
    Last Post: 01-02-2018, 07:39 AM
  2. Level 1 and Level II Remote Coder Positions
    By gfrancis in forum Job Postings
    Replies: 2
    Last Post: 05-31-2012, 10:05 PM
  3. 2 Level decompression, 1 new level, 1 redo
    By mbabou in forum Orthopaedics
    Replies: 1
    Last Post: 02-10-2010, 01:36 PM
  4. H&P performed with level 3 visit, raise level 4?
    By LynnS.321 in forum Orthopaedics
    Replies: 1
    Last Post: 10-23-2009, 07:28 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.