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Rx Drug Management - Does changing dosage

  1. #11
    Medical Coding Books
    For the second chart you posted - I got a 99214, based on detailed history, Detailed or EPF exam (95 or 97), and moderate MDM.

    MDM - Amount/complexity of data reviewed - I got as Extensive (or high - whichever) - I counted Diagnostic lab, Diagnostic X-Ray, Ordered/reviewed old records, and Diagnostic medical procedure.
    #Dx/Tx Options - Low - 1 chronic stable condition (CAD - unless it was cured - is that something that can be cured? I'm sure that's a completely stupid question to everyone else but me...) 1 new problem, not severe with good prognosis
    Risk - I put as Moderate for Rx drug management (Darvocet)...Incidentally, how old is this note? I thought that was recalled recently...

  2. #12
    Default Rx drug management and 99214
    Chart #1) I like your counting. Good food for thought. I am coming up with 99213 with 784.0 and 401.9. Det, Exp, Low. Right?

    Chart #2 (Darvocet med): You are right, if it is established, it is 99214 with 786.50. Any other Dx codes you can think of? New pt, 99203. Do you feel this a new or established pt?

    I was also trying to figure out how, or if, I should code the EKG. I went around and around with this EKG thing.

    EKG: I have a partial EKG strip that appears to have been done in the Internal Med office; and a doctor note on the strip that said "normal EKG" and he signed it. I also have a short description of rate, rhythm and sinus under the "chest" part of the exam, as you saw. What do you think on this?

    Take care and talk to you after Christmas.

  3. #13
    Case #1 - I'm conflicted on the code assignment, but I feel that 99213 is the highest that could survive an appeal with the records, even though it "technically" qualifies for a 99214, with the absolute bare minimum allowed. I really feel that this case could easily secure a 99214, if not a 99215, with better documentation. As for the diagnoses, I could use a little direction, myself. I'd have to ask a few other coders in my office to look at this and give their two cents before I decided on anything, if this were mine to work. I think the headache should be primary, but I'm not sure whether this is coded as a poisoning or a side effect - the doctor doesn't ever come right out and say that the medication was causing the HA's, but it's implied by his decision to taper it off. What's unclear to me, is whether the HA is a consistent side effect with this medication, or if it's only problematic due to the increased dosage.

    I do think that the HTN and PVC should be coded - they're definitely relevant. A part of me also wants to code the diabetes and poor glycemic index as some sort of supplemental code - even though this doctor isn't treating the condition (as far as the note indicates), since it might be significant, but I'm probably wrong about that.
    As for the levels - Detailed History, Problem focused exam at best, and MDM as moderate, because of the # of Dx/Tx Options and Risk. That said, I don't think the records have enough substance to justify a 99214, which is odd, because it seems like the patient's condition has the medical necessity to support at least a 99214. I can't give you a definitive answer without consulting with others, though.

    Case #2
    - Seems like an established patient to me, and the diagnosis as chest pain should be enough.
    - I'd code the EKG with a 26 modifier. The doctor signing the strip with his comments is sufficient to prove he interpreted it. I don't know what code you should select (Don't have my CPT), but I can tell you that ours are generally 93000 when I see them billed. That doesn't mean that's the code you'd need, though, just a place to look.
    - The rhythm falls under CV, but the rate and sinus I'm unsure of. I think that the rate is actually credited to constitutional, but only when billed with 2 other vitals, and even if the sinus is also one of those vitals (along with height, weight, etc.), there still weren't enough to qualify for the extra bullet by 1997 rules. Since the constitutional and CV systems are both clear elsewhere in the note, the rate and sinus don't add anything significant, by 1995 rules.

  4. #14
    Default Rx drug management and 99214
    Aloha. btw, I live in Hawaii. Hope you had a great Christmas.

    On Case 1) On PVC, the sentence in HPI is "He does note that metroprolol was helpful for PVC treatment." The doctor does not mention PVC in his impression, but he does mention metroprolol there. Metroprolol is used to deal with high blood pressure and chest pain after a heart attack. But is all this enough documentation to code PVC? I wish it was, but it is stretch in any case. Like you I got a 99214, but I can't remember how I did it. Metroprolol could easily be a just a tx for HTN.

    After review, I am getting a Low MDM. I don't see the moderate unless you are adding in another diagnosis. This was a follow up on a HA and HTN. So where is the moderate?

    Case 2) I agree with you, I think it is established patient, but how can I be for sure? Is there a strong reference to this being an established pt. I am leaning towards the 93000 EKG code for this encounter too. I know you don't need a modifier here, but still unsure of est. vs. new pt. thoughts??

  5. #15
    Hawaii? I'm super jealous! I'm landlocked in west Texas. Nothin' but dirt, as far as the eye can see...


    #1 - You may be right about the PVC. I only thought it was relevant because it is being affected by the Metoprolol. It was only barely mentioned, but then again, so was everything else. The doctor didn't even address how the Metoprolol was working for the HTN, which doesn't make a lot of sense to me. As far as the MDM - I'm probably giving too much credit in the #Dx/Tx Options area - the amount of documentation doesn't seem right for Moderate MDM, and the doctor kind of downplays the problem in describing the pain. If you're getting low, go with it. I'm getting moderate, though on both the Marshfield point system and on my audit tool (from Trailblazer Medicare - our local carrier). But, I am taking the PVC into consideration, since it's also a cardiac condition.
    On the Marshfield chart - I gave 1 point for "self limited, minor problem"
    I also gave 2 points for "Established problem, stable or improved - one for HTN and one for PVC.
    On my audit tool, I give one point to "each new problem for which the diagnosis or treatment plan is evident, regardless of the presence of diagnostic information"
    And 2 points for "each new or established problem for which the diagnosis or Tx plan is not evident" (the minimum #of points in that category), because the Tx plan for the HTN really isn't evident - tapering off of the Metoprolol is to treat the HA, not the HTN. How the HTN will be treated without the Metoprolol isn't indicated.

    I should note that I'm not confident about either one - I think my results are too high.

    #2 - The note doesn't explicitly say she's new, and the note "No change from 2005" about the x-ray implies that the doctor didn't have to request the record from someone else, so she's been there before. She's on 3 different prescriptions (at least 2 for chronic conditions) which require periodic visits, so she's been seen within the past 3 years, and the phrase "Advised Continued us of Darvocet" makes it seem as though the doctor is familiar with the prescription to me, since the dosage isn't mentioned. I also can't see a patient receiving long term care for cardiovascular problems, deciding to see a completely different doctor for chest pain, out of the blue; I'd think she would go to the doctor who is well versed on her history, and that she already trusts to manage her care - but that's just my opinion.

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