Results 1 to 7 of 7

does this qualify for level 4 office visit

  1. #1
    Default does this qualify for level 4 office visit
    Exam Training Packages
    Hi Coders,
    I am stumped on this example ,So please can someone help with references
    An established office patient with hypertension, diabetes and a history of dyslipidemia
    CC: Follow-up hypertension and diabetes

    Interval History: The patient's hypertension has been well controlled on current medications. Diabetes is stable as well, with no significant hyperglycemia or episodes of symptomatic hypoglycemia. Dyslipidemia remains well controlled on statin therapy.

    Medications

    Lisinopril 20 mg po qd
    Atorvastatin 10 mg po qd
    Glyburide 10 mg po bid

    ROS
    General- Negative for fatigue, weight loss, anorexia
    Cardiovascular- Negative for chest pain, orthopnea or PND
    Neurologic- Negative for paresthesias

    Pertinent PFSH is remarkable for mild OA which has been quiescent

    Physical Exam
    General: NAD, conversant
    Vitals: 120/80, 65, 98.6
    HEENT: No JVD or carotid bruits
    Lungs: CTA
    CV: RRR
    Extremities: NO peripheral edema

    Labs: BUN 12, creainine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77

    Assessment
    1.Well controlled Type 2 NIRDM
    2.Well controlled hypertension
    3.Stable dyslipidemia

    Plan
    4.Continue current medications unchanged
    5.Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
    6.Check LFTs at next visit as well due to ongoing statin therapy
    7.Continue lifestyle modifications and exercise for weight loss
    8.Return visit in four months
    Last edited by mstyus; 03-05-2010 at 11:50 AM.

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default What do you think and why?
    Well, I can give you MY assessment, but I think it would be helpful to know what you are thinking and why (yes, it does / no it doesn't because of ....)

    For a 99214 you need 2 out of the following 3 key elements:
    Detailed history
    Detailed exam
    Moderate MDM

    I'll start by telling you that by 1997 guidelines you have a Detailed History (status of 3 chronic conditions used for HPI).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 03-05-2010 at 02:30 PM.

  3. #3
    Default
    I come up with a detailed history, EPF exam and Moderate decision using the 1997 guidelines. 99214
    adrianne, cpc

  4. #4
    Location
    Johnson City
    Posts
    202
    Default
    Using the 1995 DG
    I came up with:
    Detailed History
    EPF exam
    Moderate MDM

    equals 99214
    Melissa Jewett, CPC

  5. #5
    Location
    Johnson City
    Posts
    202
    Default
    I just want to clarify I didn't use the 1997 DG's b/c I did not credit the three chronic conditions as part of the HPI. If you do credit three chronic conditions then you must use the 1997 DG's.
    Melissa Jewett, CPC

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default Carrier specific
    Quote Originally Posted by mjewett View Post
    I just want to clarify I didn't use the 1997 DG's b/c I did not credit the three chronic conditions as part of the HPI. If you do credit three chronic conditions then you must use the 1997 DG's.
    At a conference on E/M coding I attended a few years back it was pointed out that some carriers DO allow you to mix the "status of 3 chronic" conditions with the 1995 exam guidelines. (It's not my carrier, so I didn't pay closer attention.)

    F Tessa Bartels, CPC, CEMC

  7. #7
    Location
    HUNTINGTON, WV
    Posts
    21
    Default
    Yes, this qualifies for a level 4 est. patient.

    Detailed history and moderate MDM = 99214
    JENNIFER WESTFALL, RHIT, CPC, CGSC

Similar Threads

  1. ? Level on office visit
    By cnramsey in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 08-22-2012, 10:54 AM
  2. Office Visit Level
    By cnramsey in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 06-27-2012, 10:55 AM
  3. Office visit level 99215
    By cnramsey in forum Family Practice
    Replies: 0
    Last Post: 04-19-2012, 03:49 PM
  4. Replies: 1
    Last Post: 10-28-2010, 08:52 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.