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E/M Outpatient Office visit

  1. #1
    Default E/M Outpatient Office visit
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    Good Evening,

    Needing just a little help regarding presenting problems. There was insight that I had received stating that a presenting problem that is less than 72 hours with a prescription being prescribed would be a 99203 instead of a 99202. Is this true? The following example I usually would level as a 99202 regardless of time I see the plan of care being straightforward due to the fact the dr did perform a strep to figure out what is going on which came back negative and then he went on to prescribe the medication due to the ear. Can anyone let me know how they would code the following?

    Guidelines 1995

    CC: Ear pain for 3 days + sore throat
    27 year old male, new patient presents with earache ongoing for 3 days. Ear does have slight drainage, tender to touch and sore throat. Pt denies headache, nausea, cough, no discomfort of eyes.

    Medical History: Knee surgery 2007
    Family: Mother heart disease, hypertension
    Social: Occasional alcohol

    Constitutional: 100 body temp
    Pt looks state age, well groomed
    Eyes: clear, bright,
    ENMT: ear is tender, some drainage, mildly swollen, red
    throat is somewhat sore
    Respiratory: breathing is well, no crackles, etc...
    Integumentary: skin is warm to touch

    Found through examining the ear does have mild drainage, tender and red. For the throat performed a strep test which was negative. Due to the drainage, tenderness and slight swelling of the ear will prescribe ofloxacin. As for the sore throat recommended warm salt water gargles and Chloraseptic. Go to emergency department if symptoms worsen.

  2. #2
    Using the leveling guidelines I get the following (keep in mind that many coders will disagree on the assignments in the history section )

    Location = Ear Pain, Sore Throat
    Quality = Tender (some will say this is severity or sign/sym)
    Duration = 3 days
    Severity = Slight
    ROS = Eyes, Resp, Gastro, Neuro
    PFSH = Full

    HISTORY = 99203 (Detailed)


    EXAM = 99203 (Detailed)

    New Problem No Work Up
    Lab Ordered
    Moderate (prescription ordered)

    MDM = 99204 (Moderate)

    Summary =
    Hx 99203
    Exam 99203
    MDM 99204

    Overall would be 99203 for 3 out of 3. This is based on leveling only.
    Chelle Johnson, CPC CPMA CDEO CEMC CPCO CPPM AAPC Fellow
    Billing/Coding/Credentialing/Auditing Coordinator

    20+ years experience in Medical Billing and Auditing

  3. #3
    Talking RE: E/M Outpatient Visit

    Thank you so very much for your help as I was getting different answers which had me really worried about how I was handling the claims. :-) :-)

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