E/M coding help
I am having an issue with levels of E/M codes.
What would you code if this was the presenting documentation:
11 y/o, temp 98.9, wt 146, ht 58in.
Problem- pt with redness and matter x 2days of the eyes, no temp (written by nurse)
Physician doc normal- gen aspect, head, ears, nose, throat, neck, skin, heart, lungs, abdomen, etremities, hips, neuro, and developmental. He documents abnormal eyes- bilat eye redness.
Diagnoses given- conjunctivitis and URI
Treatment- vigamox and rondec DM
temp 96.8, c/o runny nose since last night, per mom temp last night but not taken (written by nurse)
MD writes normal exam as above except the abnormal is nose-mucus.
Dx is URI
Plan- rondec DM and motrin.
Please let me know what you would code for these two visits.
New patient? Established patient? Inpatient?
I can't really tell from this but I'm going to assume these are established patient office visits.
Important note- your doctor is confused in documenting his exam vs documenting ROS. He can't just list all the systems and say "normal" and get credit for a comprehensive exam. (He can say "all other systems reviewed and negative" when he's doing the ROS.)
For an established patient you need to meet two of the three key elements to get your level of service.
Visit # 1
You have no history.
You have an EPF exam (1995 guidelines) - eyes & constitutional (it is okay for ancillary staff to record the vitals as long as MD reviews)
You have Moderate MDM (3 problem points for new problem conjunctivitis w/o workup and moderate risk for Rx management)
This equates to a 99213 (although the documentation is very poor).
NOTE: Diagnosis is conjunctivitis and URI but he "documented" his exam as all "normal" except for the eyes. Where's the URI come up?
Visit # 2
Not sure if this is the same patient? And if it is, how far apart these visits occurred.
You have no history
You have an EPF exam (1995 guidelines) - nose and constitutional.
You have SF MDM (1 problem point for established problem URI; low MDM - I'm assuming the "Rx" are really OTC drugs)
This equates to a 99212.
Hope that helps.
F Tessa Bartels, CPC, CEMC
Thank you for your response. The patient is an established patient and the visits were about 4 months apart.
I have difficultly with this physician because he never writes any history, hpi, etc or acknowledges he reviewed it. Sometimes it will just state runny nose and that is it. There is never any ROS or any other detail. He will always document a complete physical (he checks a box off under normal or abnormal) and sometimes documents one or two abnormals such as nose-mucus. He then documents several diagnosis codes. Can you count diagnosis codes when there is no documentation to support? Our physician counts all the diagnosis codes whether there is documentation or not. She also counts the full physical despite lack of medical necessity.
What if there is a senario such as patient complains of sore throat. Afebrile. Exam documented as normal (including throat). Then provider orders a strep culture (which I do not believe is medically necessary) and the gives a diagnosis of URI, Allergic Rhinitis, and Tonsillitis. Then prescribes antibiotics. I have a hard time because medical necessity is not really documented.
Any other advice would be appreciated.
Thanks so much,