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Thread: Level 99214 (Help)

  1. #1

    Default Level 99214 (Help)

    AAPC: Back to School
    I just attended some conferences with a company I will not name, and we were told that if for example a patient comes in and they are on a prescription related to one of their problems, and the doctor just documents and tells the patient that they need to continue it (in his words, "even if they have enough for 5 years at home) then if you meet the HPI (4) and the other parts of history, it automatically becomes a 99214 because of the mention of the prescription. I totally disagree but would love someone else's input.

    My theory is if someone comes in for vaginitis as a new patient with a new problem and given a cream for example then yes you very well could have a 99204 if everything is met but if that same patient comes back for her follow up and you tell her to continue with the cream, this does not meet a 99214.

    In my mind, medical necessity should play a larger role. A UTI follow up a 99214? I really highly doubt it. He instructed to the physicians that they did not even need to go over social history if they reviewed medications since this gives them the (1) they need. I just find this as a terrible way to direct physicians. This same patient may have recently been divorced, lost a child etc and may very well have a new dx of depression.

    Any and all comments would be greatly appreciated!

    Have a good weekend


  2. #2
    Join Date
    Apr 2007
    Everett, WA


    This is my "student" opinion and only based upon limited study experience. First of all when the patient returns for the F/U it's not stated whether or not the patient's condition is improving or stable. That factor would be important in determining whether the overall MDM factor would be low or minimal. No exam was given, and being a returning and now established patient you only need the HX and MDM which in this case COULD be a 99213 or 99212, but surely not a 99214. The medication management as moderate is only one tenant of the MDM process and even with the MDM proving to be minimal or low, you still can't boot this up to a 99214I'm interested in input from the experienced veterans and coders of this field, too, as I hope my comments are on the right track and if not someone can set me straight! ---Suzanne E. Byrum, CPC

  3. #3


    My thoughts exactly. If I were to assume that they met the (4) in the HPI and even met (1) in the PFSH, this gentleman was stating that the physician telling the patient (and documenting) that she was to continue with the cream for example this makes it a 99214 since they addressed the prescription. I think this is taking the MDM way out of context. I appreciate your input.

    Thank you

  4. #4
    Join Date
    Apr 2007
    White Plains, NY


    From the point of view of a fraud investigator, we want to see that the E/M is driven by the CC. Just because the patient is on Rx meds for some problem unrelated to the CC, does not automatically kick this up to a 99214. There is no medical necessity driving the encounter.

    If the number of level four visits from this provider is not the same as his peers, he may get singled out as an outlier and get audited by a plan's SIU.


  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Documenting 99214

    The appropriate documentation for a 99214 visit requires two of the three:

    Detailed History = 4+ HPI elements (or status of 3 chronic conditions) -AND- at least 2 systems in the ROS -AND- at least 1 item of pertinent PMFSH.

    Detailed Exam = 1995 Extended exam of affected area/system, plus other related/symptomatic systems -OR-
    1997 At least 2 elements from each of 6 areas/systems -or- at least 12 elements in 2 or more areas/systems

    Moderate MDM = 2 of the following 3
    3 problem points
    3 data points
    Moderate risk

    The Rx management is moderate risk, but how do you get 3 problem points or 3 data points from a patient who comes in for a F/U and things are improving, but you want them to continue the Rx for another X days? You have an established problem, improved which is only 1 problem point. Even if you feel you have to order labs, that's just 1 data point. I don't care if you are prescribing morphine, or planning major surgery ... you still need either the problem points or the data points to get to moderate risk.

    That consultant is giving an extremely simplified version of what an auditor looks at and some physicians will selective hear that it's okay to do this. Too bad.

    F Tessa Bartels, CPC, CEMC

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