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99202 or 99203

  1. #1
    Default 99202 or 99203
    Medical Coding Books
    Need a second pair of eyes, WC changed the code from 99203 to 99202. What do you get?

    Here is the chart note:

    51-year-old male who works for a utility district and does a lot of opening and closing of water valves. This patient was doing this repetitively about a month and a half ago and he began to experience right shoulder pain. The pain has persisted and is worse when he tries to reach above shoulder level or reach behind him. He denies paresthesias or paralysis. No neck pain. He had no shoulder problems in the past. He has gone through three visits of physical therapy at this point without much pain relief.

    PAST MEDICAL HISTORY:
    See medical questionnaire in the chart.

    PHYSICAL EXAMINATION:
    The right shoulder presents with no swelling or gross deformity. He has full active range of motion of the shoulder which is symmetric with the left. He is tender to palpation in the subacromial space laterally with deep palpation, and he had positive impingement signs. There is no anterior apprehension. The patient has 5/5 strength around the shoulder and a normal sensory exam in the right upper extremity.

    PROCEDURE:
    A PARQ conference was held before a mixture of LIDOCAINE, MARCAINE, and DEPO-MEDROL was injected into the subacromial space of the right shoulder, giving this patient excellent pain relief shortly after the injection.

    IMPRESSION:
    Impingement, right shoulder.

    PLAN:
    Subacromial steroid injection as noted above and physical therapy for rotator cuff strengthening. I will see the patient back in the clinic in a month for reevaluation. I will keep him on limited duties at work until that time.


    APRIL 27, 2010

    X-RAYS:
    Outside radiographs as well as radiographs taken today of the right shoulder on this patient show some mild acromioclavicular hypertrophy and a type I to II acromion, but are otherwise unremarkable.
    Ann

  2. #2
    Location
    Kansas City, MO
    Posts
    431
    Default
    A 99203 requires a detailed HX and EXAM. I dont see it.
    Theres no ROS....well besides what I pulled that was extra from the HPI. I can't give credit for HX (except social if you count that he documents he works and where) without seeing the form (which should be dated and signed)

    Not a 99203, sorry. Hx from what I can see is only EPF.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. Default
    History and MDM are okay to bill 99203. But PE is not detailed. So the final level that can be reported is 99202.
    Thanks,
    Jagadish, CCS-P, CPC

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Based on PE I agree it is 99202.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default Medical Nurse Auditor
    based on my training in CPC, 30 years of nursing, and that I had the same problem, I would agree with the level 02 coding. You did not mention patient's level of reported pain.

  6. #6
    Location
    Dallas, Georgia
    Posts
    12
    Wink 99202 or 99203
    I agree I would code as 99202 based on the Limited PE the History and MDM are okay for a 99203.

    Tanya Thompson, CPC CPAR
    Tanya M. Thompson, CPC, CPAR

  7. #7
    Location
    Kansas City, MO
    Posts
    431
    Default
    Ok, what am I missing? How are you all getting a level three on the HX on this new patient??
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  8. #8
    Location
    Kansas City, MO
    Posts
    431
    Default
    Never mind

    I see what I did...I was thinking complete ROS for a level 3, durh...I know better.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

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