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Thread: E/M experts pleeeeeeeeeeeease.

  1. #1
    Join Date
    Apr 2007

    Default E/M experts pleeeeeeeeeeeease.

    AAPC: Back to School
    Say we have a case of bronchitis or even pharyngitis, dealing with an (establish patient). And are HPI is met for a level 4 and are ROS is met for a level 4. Then are exam is met also for a level 4. And the physician injects a shot of Rocephin. Does this administration count, as a prescription of drug management. Meaning would this count as a Moderate MDM. Curious to see what the coding world see's. If yes. Would you pull a level 4 out of this.

    Even if the exam is not met.


  2. #2


    If you are billing for an established patient, then you need 2 out of 3 components. You have a level 4 for HPI and exam-I would bill the level 4.

  3. #3

    Default E/M experts pleeeeeeeeeeeease.

    In order to qualify for a level 4 Hx, it takes 3 of the 3 areas of Hx; HPI, ROS and PFSH. A detailed Hx on on a level 4 includes 4 elements of the illness, at least 2 ROS questions not already counted in the HPI and a pertinent PFSH. A detailed exam includes 6-7 organ systems/areas or 12-17 bullets. However, sometimes the nature of the illness needs to be taken into consideration, not just counting systems and bullets and such. Yes this adds if the Hx and Exam is detailed it adds up to a 4. But unless this patient has risk factors like COPD or multiple chronic illnesses also taken into consideration, the Hx and Exam seems excessive and padded. Otherwise, pharyngitis is considered a self-limited, minor problem, Rx or no Rx. Just an opinion from someone who has been performing E/M auditing for nearly 10 years.


  4. #4


    You only need 2 out of 3 key components required for est. pt. So, you use the HPI and MDM. If the E&M is separately identifiable from the (reason for the)injection then submit 99214-25; CPTinjcode; supplycode (if doctor's office).

  5. #5


    Just as an FYI to Sandy, if you do any IM, IV meds, there is an increase in the MDM regardless. There is a risk of acute reaction, etc. Just because the dx is pharyngitis does not mean that nothing else in the MDM matters. I also have been both coding and auditing for over 12 years.

  6. #6
    Join Date
    Apr 2007


    You should make sure to use the 25 modifier on the 99214 and bill the 90772 admin code for the Rocephin.

  7. #7
    Join Date
    Apr 2007


    Why would you use 99214 instead of 99215? If 2 out of 3 key components were meet at level for, wouldn't it be 99215?

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