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Thread: Need Help Please

  1. #1

    Default Need Help Please

    AAPC: Back to School
    I am auditing one of my provider's charts and I am on the fence here and would like other's opinions please. This patient presented for a follow-up on two conditions and then also complains of sinus problems. The provider diagnoses the patient with sinusitis and thrush and prescribes two different antibiotics. Plus, he changed the medication on one of the chronic condtions.

    Here is my problem.....clearly the MDM here is of the moderate level, but my history and exam only equate to EPF. The provider billed a 99214 for this encounter and I do see where the medical necessity would support that, but the history and exam doesn't.

    Am I correct here that I would have to report 99213 based on ths history and exam even though the medical necessity would support 99214?

    Just wanting to see how others would handle this. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
    Apr 2007
    Carmel, New York

    Default Would agree with 99213

    Since you have two of the three elements, I would agree with 99213. I am assuming your exam fell into EPF using both 95 and 97, correct?

  3. #3


    You are correct. I have a feeling the physician is going to dispute this one because the medical necessity is there, but.....
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  4. #4
    Join Date
    Apr 2007
    Evansville Indiana

    Default 99213

    You still need 2 of 3. MDM is only one element and without either a detailed history or exam this would still be a 99213.


  5. #5


    I agree. You have to have 2 of 3 and if the history and exam don't meet detailed, then 99214 isn't an option.


  6. #6
    Join Date
    Apr 2007


    In response to this, how would you handle this? A patient,(me) saw her pcp for (5 minutes) for a followup ER exam of a Kidney infection The Dr. billed it out as a 99214, completely unsupported, what should I do? Ignore or pay my portion of charges for the office visit and urine culture that she submitted even though there wasnt enough to culture as well as useless since I was on anitbiotics. I know she was wrong - I know what took place and what didn't during the visit, i'm not sure what her notes say, afraid to ask for them, cuz, then I would have to report it. What would you do? I have decided to change PCP's. thanks.

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