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advice on E/M level

  1. Default advice on E/M level
    Medical Coding Books
    Our family physicians do pre-op physicals for surgery. They always want to bill a 99214. However, I question whether they should really be a 99214 or a 99213 according to their documentation. For example:

    Chief complaint: lump on the left leg, very painful.
    HPI: 49 yr old man who hurt his left anterior leg when he stepped off a truck at his job. He developed a left anterior compartment fascial herniation. He is scheduled to undergo a left leg closed anterior compartment fasciotomy. This will be done on 8/05/10 by Dr. Surgeon. I was asked to see him for preoperative clearance.
    Past medical illnesses: none
    Current medications: none
    Allergies: none
    Previous surgery: He had skin grafting of rt lower extremity secondary to a car accident.
    Family history: His mother has diabetes, grandfather died of a stroke in his 80's.
    13 review if systems: is essentially negative.
    Exam: Temp : 98.2, Pulse:68, Respirations: 20, B/P: 128/82, Wt.209
    Heent: TM's intact, no fluid,no discharge. Posterior oral pharynx-no erythma, no edema or exudate. Mucous membranes are moist.
    Neck: SUpple. Lung: clear to auscultation. Heart: regular rate & rhythm.
    Abdomen: soft, neontender, good bowel sounds.
    Extremities: he does have a bump on the left anterior shin, very tender to palpation. Neurological: Alert, orientated. Cranial nerves II throught XII are intact.
    Assessment: Left anterior compartment fascial hernia.
    Plan: He is an acceptable surgical candidate.

    Any information I can give to the physicians would be most appreciative.

  2. Default
    We have EPF history, Comp PE (1995) and MDM Mod (if the problem is new) and Low (if the problem is est).

    If the problem is new to the examiner, the level is 99214
    If the problem is est. to the examiner, the level is 99213.
    Jagadish, CCS-P, CPC

  3. #3
    Harrisburg, PA
    Wink Actuallly .. that is a 99215
    Hi there I have scored out a comprehensive history and exam. Let me explain:

    He has location (leg), quality (bump), associated signs (pain) and context (fell off truck).

    ROS .. it says a review of 13 systems essentially negative .. that is allowable. He also touched on msk and allergies.

    He has a complete PSFH.

    PE is constitutional/ent/cv/resp/gi/msk/skin and psych which is 8.

    CMS allows for the ROS "ALL OTHERS NEGATIVE" or some variation thereof.


  4. Default
    Lump is the chief complaint here. the other HPI elements should describe about this lump.
    We have location (leg) leg when he stepped off a truck at his job (context) and very painful (severity). There is no quality here.
    Jagadish, CCS-P, CPC

  5. #5
    Columbia, MO
    I agree no quality and no complete PFSH as there is no social history at all. And MDM I get low or even straightforward, there is only 1 dx, there is no complexity at all that I see and a decision for surgery so reall I am stretching for low and would really go straightforward. so I see EPF hx, a detailed exam and straight forward MDM so I go the level 99213.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Harrisburg, PA
    Red face
    Seeing as I code strictly for Medicare(CMS), I was going by our policies and what CMS allows. For a 99214, the provider, for a complete PSFH only needs TWO of the components, and he has family and social which would make the history complete.

  7. #7
    CMS does allow for the ROS short cut but CMS also recognizes 14 systems. We have been told by WPS Medicare that we only have 2 ways of documenting this. List the systems individually or state "all other systems reviewed and are negative". They will not count statements that only refer to a number of systems if that number is less than 14.

    The only ROS I see is allergies. So that puts this down to EPF. You are correct that you only need 2/3 on PFSH for established patients.

    The other issue is one that Tessa has brought up many times previously, this really shouldn't be an E/M code at all. This is part of the global surgical package and should be billed with the procedure code and the modifer indicating this was pre-op care only.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

  8. #8
    Columbia, MO
    LOL you are absolutely correct! I got so caught up it the discussion of visit level I failed to see that it was for preop! You are soo correct it should be the procedure code plus the 56 modifier. Thanks for catching this Laura.!

    Debra A. Mitchell, MSPH, CPC-H

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