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Problem Focus

  1. #1
    Default Problem Focus
    Medical Coding Books
    I am starting to audit charts for 11 pediatricians and some of our doctors love to use 99212 (problem focus), but all their documentations shows a level 99213. When going over the charts with them they ask then when would you ever bill a 99212. Could you send me some examples as to when they would bill a 99212.

  2. #2
    A common one in our peds offices would be the follow up from say OM or an URI.

    If there is only one problem and it is resolved or resolving generally your MDM is going to be straightforward, and your exam is usually problem focused.

    Hope this is helpful,

    Laura, CPC

  3. #3
    ok - but in their exam they are checking more than one body part for resolved OM - they also listen to their heart/lungs - so I wold have a EPF exam.

  4. #4
    They may have an expanded problem focused exam, but in order to get up to 99213, they would also have to have an expanded problem focused history or medical decision making of low.

  5. #5
    Duluth, Minnesota
    there are a BUNCH of examples of "each" level of E/M in the back of the CPT book. at least in the one I have, CPT 2009 Professional Edition, AMA. Starting on page 494, Appendix C.
    Donna, CPC, CPC-H

  6. #6
    Here is a scenario for OM resolved:

    Chief Complaint: f/u ears
    HPI: 10 mos old male here for f/u of recent left OM. Since having PET places, pt has had 3 infections in left ear. I have had some concern regarding seeing consistent blockage of left PET and ? if it is functioning. Per mom did well on Omnicef and Ciprodes gtts. Tried to use gtts to loose any blockage of tube. Mom says first night she used drops she got out some black hard drainage, but non since then. Eating well. Sleeping well - up a couple of times overnight nast night. Acts find. No recent fevers. No cold sx. some eye drainage from right eye this AM, slightly more than normal.

    PSFH: reviewed - no changes required)

    General: alert in NAD
    External Eye Exam: some redness to skin just beneath right eye lid
    L TM: normal, used cerumen spoon to remove cerumen, outer ring of PET visible howeer still see hard dried blood/vs cerumen
    R TM: normal, PET visualized
    Lungs: clear without rales or wheezing
    Heart: normal S1 S2 without murmur

    How would you code?

  7. #7

    Mod Factor - well on Omnicef
    Location - Ear
    Assoc. Sign - Drainage (from ear)
    Quality - Consistent (blockage)

    ROS -
    no Fever (constitutional)
    Drainage (from eye - eyes)

    Medical Hx - tubes
    Fam Hx - mother (assuming they live together...)

    Detailed History


    Ears (ENT)

    I'd use Detailed based on 1995 guidelines...because of the "Detail" on the ear exam


    Established problem, worsening .... hence the "3 ear infections since tube placement & the physician questioning functionality of tubes" .... 2 points

    That's as far as I get with MDM because I don't have the rest of the note.

    But based on the detailed history and detailed exam, that would give you 99214

    Just my take...any others?
    Last edited by ARCPC9491; 04-06-2009 at 09:05 AM.

  8. #8
    Based on 97 guidelines that is a problem focused exam.

    So if you have 1 problem resolving, 1 point, or worsening 2 points (I am guessing no data points involved), no rx management so that would keep you at either straightforward or low (depending on what dx point you give credit for). This could be either 99212 or 99213 based on MDM.

    Thats my take on it,

    Laura, CPC

  9. #9
    Medical necessity needs to enter the picture also. Is it medically necessary to bill an expanded problem focused exam for a single complaint of say, OM?

  10. #10
    This may OM, but the poor child has had 3 ear infections since tube placement, it's continually getting worse, blockage/drainage, etc. From the limited information I have, history and exam, the documentation supports 99214. Now, I would like to see the rest of the note to see what the provider is going to do next to prevent the reoccuring infections, meds seem to work, but they keep coming... if the tubes aren't working maybe further work up is necessary, tube replacement, etc.... this isn't your standard case of OM. This clearly is not something that is going to go away on its own.
    Last edited by ARCPC9491; 04-06-2009 at 09:51 AM.

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