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I need E/M expert. PLEASE. ?????

  1. #1
    Default I need E/M expert. PLEASE. ?????
    Medical Coding Books
    I'm new to this E/M coding. Starting to get my feet wet, working for this Family Practice in O.C. I'm doing the internal audits for this practice. Looking to gain money for them, versus trying to strike down every code I see with not enough doc.
    With this said my QUESTION.

    Say we have a patient with a New problem, of just Pharyngitis or Cough with URI or Bronchitis. And we do a exam of 5 to 7 organ systems. With a prescrition of Antibiotic issued.

    What level is this for an establish visit.
    I want to give this a level 4. It seems that the two out of three are met. But I'm told by some, that Pyharyngitis or just a cough with URI is to weak of an diagnosis.

    Need some opions out there.

    Thank You.

  2. #2
    Default
    Without seeing the documentation, I could only guess, but I would say that the complexity of the presenting problem would only merit a medical necessity of a level 3.

  3. #3
    Location
    Cactus Wren
    Posts
    14
    Default Level 4 vs 3
    For us, the decision making for this type of visit is no question a level 4. Its a new problem and moderate complexity risk due to the rx. According to the AMA coding guidelines in this case with the exam being a level 4 you can code a 99214. I get nervous when its a Medicare patient although they say that the decision making should drive the code. I struggle with this one too just because it appears to be such a straight forward visit. If the patient has any co-morbitities, this will help support the level 4. Generally, we code these a level 3 if there are absolutely no other issues being addressed.

    I will be watching this thread closely to see what others are doing.

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Wink
    I guess my "opinion" would be based on the actual diagnosis. If it is just Pharyngitis, 99213; but if it is Bronchitis, why not 99214? Bronchitis is a higher risk infection than a simple Pharyngitis.
    Lisa

  5. #5
    Default
    Thanks to all you, who let there thoughts be known. Glad to see I'm not the only one on the fence pertaining to this question.

  6. #6
    Default
    I'm also a new coding auditor for EM. I've struggled and fought with our doctors over this exact same scenario. Even though it is a new problem, new medicine, documentation is there, I would code a cough or URI as a 99213. The Medical Decision making is truly what I look at. If the patient has comorbidities and other problems that are addressed at the same time, I would bump up the code, but a cough or URI is low risk to the patient.

  7. #7
    Default
    Do you have a link to register for this seminar?

  8. Default
    Even with a dx of bronchitis, without any comorbidities I would only code this scenario as a 3rd level est pt or 2nd level new pt. Coming from the urgent care setting, I see a lot of bronchitis and my doctors think that a dx of bronchitis or pneumonia is automatically a 4th level visit, but they don't provide enough documentation. In these situations, I look at comorbidities and tests done to assess the patient's condition.

  9. #9
    Location
    Pueblo, Co
    Posts
    14
    Default Billie
    If the doctor documents the EM as a 99214 or 99215 if we get a denial from our electronic filing that states documentation does not support this code can we change it?

  10. #10
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    Quote Originally Posted by daniel View Post
    I'm new to this E/M coding. Starting to get my feet wet, working for this Family Practice in O.C. I'm doing the internal audits for this practice. Looking to gain money for them, versus trying to strike down every code I see with not enough doc.
    With this said my QUESTION.

    Say we have a patient with a New problem, of just Pharyngitis or Cough with URI or Bronchitis. And we do a exam of 5 to 7 organ systems. With a prescrition of Antibiotic issued.

    What level is this for an establish visit.
    I want to give this a level 4. It seems that the two out of three are met. But I'm told by some, that Pyharyngitis or just a cough with URI is to weak of an diagnosis.

    Need some opions out there.

    Thank You.
    hi daniel -
    I'd go with a level 4 est E/M. It is what it is - it supports a level 4 even if the History component falls short. The Exam and MDM are there. In all my years of coding, I've actually never heard that pharyngitis or cough were not "strong" enough dx's for coding a "high" level E/M.! (I guess I learn something new everyday). That being said, I still say, it is what it is and if documentation supports a level 4 E/M I don't see any reason not to code it out as such. I will say however, that most sore throats, even strept visits that I've coded are usually at a level 3. But I wouldn't have a problem coding a level 4 if documentation supported it.
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

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