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Time-Based Coding

  1. #1
    Savannah, GA
    Default Time-Based Coding
    Medical Coding Books
    This patient was seen 1 week prior and was called in to discuss lab results because of her TSH being out of range. Is the documentation sufficient/detailed enough to bill based on time?

    Patient is a 56-year-old female. This is a follow-up visit.


    Patient to be evaluated for acquired hypothyroidism. This was first diagnosed several years ago. She is currently taking Synthroid. TSH was last checked 5 days ago. The result was reported as.025. She denies any related symptoms. Reviewed labs with patient. Her cholesterol, chem panel and CBC were reviewed. The patient was on steroids and had had a steroid injection 1 day prior to her blood draw.

    CONSTITUTIONAL: Negative for chills, fatigue, fever, and weight change.
    E/N/T: Negative for hearing problems, E/N/T pain, congestion, rhinorrhea, epistaxis, hoarseness, and dental problems.
    CARDIOVASCULAR: Negative for chest pain, palpitations, tachycardia, orthopnea, and edema.
    RESPIRATORY: Negative for cough, dyspnea, and hemoptysis.
    GASTROINTESTINAL: Negative for abdominal pain, heartburn, constipation, diarrhea, and stool changes.
    MUSCULOSKELETAL: Negative for arthralgias, back pain, and myalgias.
    NEUROLOGICAL: Negative for dizziness, headaches, paresthesias, and weakness.
    PSYCHIATRIC: Negative for anxiety, depression, and sleep disturbances.

    Past Medical History / Family History / Social History:

    Past Medical History:

    Hepatitiis B 1978

    Problems with pregnancy have included 4 ectopics.
    Not currently using any form of contraception.
    Menarche occurred at age 12.
    Menopause at age 52.
    Last Pap was 2008
    Last mammogram was 2008

    Orthopedist: Dr. Mihelic

    Surgical History:

    removal of right fallopian tubw;

    Family History:
    Father: Coronary Artery Disease
    Mother: Hypertension
    Brother(s): 1 brother(s) total
    Sister(s): 1 sister(s) total; arthtitis
    Paternal Grandfather: Died at age 94; Congestive Heart Failure
    Paternal Grandmother: Died at age 89; Hypertension
    Maternal Grandfather: Died at age 94; Congestive Heart Failure

    Social History:
    Occupation: Nurse
    Marital Status: Married
    Children: None
    Exercise: Primary form of exercise is walking. Frequency is daily.

    Tobacco: Currently smokes cigarettes.

    Drinks alcohol on a social basis only.

    Substance Abuse History:

    Mental Health History:

    Communicable Diseases (eg STDs):
    Reportable health conditions; NEGATIVE

    Current Problems:
    Acquired hypothyroidism

    No Known Drug Allergies.

    Current Medications:
    Cytomel 25mcg Tablet Take 1 tablet(s) by mouth daily
    Synthroid 0.1mg Tablet Take 1 tablet(s) by mouth daily



    Current: 5/12/2009 8:33:04 AM
    T: 98 F; BP: 121/82 mm Hg; P: 78 bpm; R: 20 bpm
    O2 Sat: 98 %

    GENERAL: well developed, moderately obese; well groomed; no apparent distress;


    244.8 Acquired hypothyroidism


    Meds Prescribed:
    Levothroid 0.088mg Tablet Take 1 tablet(s) by mouth daily #90 (Ninety) tablet(s) Refills: 4


    Acquired hypothyroidism Elevated fasting glucose is likely secondary to steroids but recommended patient watch simple sugars and carbs.

    MEDICATIONS: I will decrease the dose of her Levothroid. 25 minutes spent face-to-face with patienT, over 50% of time spent in face-to-face discussion about the above assessment and plan.

    Levothroid 0.088mg Tablet Take 1 tablet(s) by mouth daily #90 (Ninety) tablet(s) Refills: 4

  2. #2
    I would say yes, this supports a 99214 based on time.

    Laura, CPC

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