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Thread: E/M dilema

  1. #1

    Default E/M dilema

    AAPC: Back to School
    I'm auditing for a physician that has come out as an outlier for CPT code 99214, in one particular note the physician has a comprehensive history and a comprehensive exam, but my medical decision making is a low, as the patient only had Vaginitis w/o medication RX. I understand that the MDM should be the leading factor for documentation, so besides stating to this physician that they are over documenting for a "Low" problem what would you code this visit?

    99215 ( which documentation supports but not MDM)
    99214 ( what the physician billed)
    99213 ( what the MDM supports)

    any advise would be greatly appreciated.

    Thank you,
    Ivonne, CPMA

  2. #2
    Join Date
    Apr 2007
    Northeast Kansas (NEKAAPC)


    Not every patient will require a comprehensive history and examination. It sounds as though this has been identified as a pattern. I would want to review the E/M guidelines with the provider and show them to start with the medical necessity of the visit and to document the history and examination accordingly.

    If you are looking at black and white E/M guidelines, it appears this might be a 99213; however, I would ask the provider why they see this as a higher level visit (did something else occur in the exam room which did not make it into the documentation?). This could be the perfect educational opportunity for both you and the provider!
    Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC, CRC
    AAPC ICD-10-CM/PCS Training Expert

    Kindness is contagious-PASS IT ON!

  3. #3


    Brenda thank you for your quick response. I will definately discuss this with the physician, because it is definately a pattern that I am seeing with their documentation. Thank you for your help.


  4. #4
    Join Date
    Apr 2007
    Columbus, OH

    Default Did he really do it?

    We have a similar level 4 outlier who uses macros in his dictations which all end up sounding eerily similar. We've also received complaints from patients that the doc's dictations did not reflect the actual physical exam. I am afraid the problem will get worse with an EMR in our future. So, if all your provider's histories and physical exams have the same high bullet point count, could he be using stock dictations and templates?
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group

  5. #5


    I definately agree. we also have another physician that uses EMR that I have my doubts about as well. This particular physician that i am currently auditing uses a template, which I will have to bring up once I give them my results. What I am coming across alot is that physicians are not as well versed in the documentation guidelines, and are relying on their coders/billers to do it correctly. Which to me in most cases is false reassurance. Unfortunately there are not nearly enough Certified/educated codes.

    Ivonne, CPMA

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