Page 1 of 2 12 LastLast
Results 1 to 10 of 13

What do level do you get?

  1. #1
    Question What do level do you get?
    Medical Coding Books
    I'm getting 2 different opinions on the level of service for this office follow-up. I'd appreciate any feed back.

    Thanks!

    HPI: The patient presents to the office today for follow-up without complaints. She is doing well. The patient has a history of supraventricular tachycardia status post readiofrequency ablation. She has had no issues since the ablation.

    Current Medications: The patient's current medications include Klonopin 0.5mg as needed.

    Physical Exam: Blood Pressure: The patient's blood pressure is 120/60. Heart Rate: 96 Neck Exam: The neck is free of any bruits. Chest: The lungs are clear to aucsultation. Cardiac Exam: S1 and S2 ausculatated. Abdomen: Soft, pliable. Extremities: Pulses are present in bilateral lower extremities. There is no significant edema noted.

    Diagnostic Impression:
    1. Supraventricular tachycardia status post radiofrequency ablation - patient doing well.

    Plan of Action:
    1. The patient is to follow-up in one year or sooner if necessary.

  2. #2
    Default
    I am not an Expert still I tried and came up with 99213

  3. #3
    Default
    I hope you have a chief complaint somewhere else because I don't really see one in the HPI.

    Assuming that the follow-up is for the "supraventricular tachycardia status post readiofrequency ablation", I say it is a 99212.

    Laura, CPC

  4. #4
    Default
    well for MDM,
    you have an established problem, stable ... 1 point
    no data
    for risk -- stable illness
    so MDM is SF

    for the exam,
    using 95 DG's .... you have const, cardio, resp, gi ... the neck exam, extremities and edema are apart of cardio .... you could argue that since he examined 4 elements in the cardiovascular system, it is a detailed exam.

    so, since it's a follow up, using MDM and the exam, you get 99212

    also -- how long ago was the ablation? does it have a global period? if so, this would be a 99024, postop visit and not billable.
    Last edited by ARCPC9491; 07-01-2009 at 09:54 AM.

  5. #5
    Default
    How are you getting Low MDM? 1Dx pt, no data, low risk= straightforward

    Laura, CPC

  6. #6
    Default
    I corrected it. I added 2 points in my head for the dx for some reason. I need to proofread my posts

  7. #7
    Default
    I'm leaning towards a 99212

  8. #8
    Default
    I also came up with a 99212, based on problem focused history, detailed exam and straight forward MDM (though only 2 of those 3 are needed).
    I share Laura's concern that the chief complaint is not clearly stated until you get to the MDM section. I would advise the provider to expand on "follow-up" with something like "of supraventricular tachycardia" - this would be a teaching opportunity for future notes.
    And as stated by ARCPC9491: check the dates to make sure it doesn't fall into any possible global period.
    Karolina, CPC, CPMA, CEMC

  9. #9
    Default
    Quote Originally Posted by Karolina View Post
    I also came up with a 99212, based on problem focused history, detailed exam and straight forward MDM (though only 2 of those 3 are needed).
    I share Laura's concern that the chief complaint is not clearly stated until you get to the MDM section. I would advise the provider to expand on "follow-up" with something like "of supraventricular tachycardia" - this would be a teaching opportunity for future notes.
    And as stated by ARCPC9491: check the dates to make sure it doesn't fall into any possible global period.
    I'm a little confused. How do you get a detailed exam ? We use the 97 guidelines so i am not familiar with 95, if that's how you got it.

  10. #10
    Default
    [QUOTE=ARCPC9491;62391]well for MDM,
    ...

    for the exam,
    using 95 DG's .... you have const, cardio, resp, gi ... the neck exam, extremities and edema are apart of cardio .... you could argue that since he examined 4 elements in the cardiovascular system, it is a detailed exam.

    ...

    I hope this works - I came to the same conclusion as ARCPC9491, my detailed exam is based on the 95 guidelines which simply state that you need 2 - 7 Organ Systems and/or Body Areas, extended exam of affected BA and other or related OS(s). In this case there are 4 items examined and the cardiovascular system exam was extended.
    However, in this case the exam may be the highest of the 3 key elements, but doesn't impact the overall level.
    Karolina, CPC, CPMA, CEMC

Page 1 of 2 12 LastLast

Similar Threads

  1. Replies: 1
    Last Post: 01-02-2018, 06:39 AM
  2. Level 1 and Level II Remote Coder Positions
    By gfrancis in forum Job Postings
    Replies: 2
    Last Post: 05-31-2012, 09:05 PM
  3. 2 Level decompression, 1 new level, 1 redo
    By mbabou in forum Orthopaedics
    Replies: 1
    Last Post: 02-10-2010, 12:36 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, 06:28 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.