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Thread: Need e/m level input on this visit

  1. #1

    Default Need e/m level input on this visit

    AAPC: Back to School
    My provider states he was told he can charge a 99215 due to to the monitoring of potentially lethally toxic chemotherapeutic agents. Does the documentation below support a 99215?

    Referring Provider:
    Primary Provider:
    CC: f/u Hep C.

    History of Present Illness:
    Patient presents today for Hep C f/u. He/she has now completed 24 weeks of tx -- his/her viral load was negative this week. His/her CBC shows mild anemia, mild thrombocytopenia and mild depressed WBC. LFT's continue to improve.

    Past Medical History:
    chronic right hip pain
    hepatitis C
    -Genotype 3a
    - s/p 24 wks tx with IFN + Ribavirin
    - undectable viral load at 24 weeks
    - need to recheck in 6 months

    Past Surgical History:
    Reviewed history from 03/10/2009 and no changes required:
    tib fib fx repaired
    right hip surgery
    repairs from tendon lac to right wrist

    Family History:
    Reviewed history from 11/03/2010 and no changes required:
    dad and grandfather died of stomach cancer

    Social History:
    Reviewed history from 03/10/2009 and no changes required:

    Risk Factors:

    Tobacco use: quit
    Year quit: 2011
    Drug use: prefer to discuss with physician
    HIV high-risk behavior: no
    Caffeine use: Drinks coffee, soft drinks times per day.
    Alcohol use: yes
    Type: Drinks beer, liquor 1 time per month having 3-5 per occasion. Rarely has more than five drinks per occasion.
    Exercise: yes
    Times per week: occasionally /wk
    Type: swimming, walking
    Seatbelt use: 100 %

    Review of Systems

    Complains of fatigue and malaise.

    Denies nausea, vomiting, abdominal pain, abdominal bloating, and change in bowel habits.

    Vital Signs:

    Patient Profile:
    Height: 72 inches (182.88 cm)
    Weight: 213.2 pounds
    BMI: 29.02
    BSA: 2.19
    Temp: 97.3 degrees F tympanic
    Pulse rate: 68 / minute
    Pulse rhythm: regular
    BP sitting: 120 / 76 (left arm)
    Cuff size: regular

    Vitals Entered By:

    Physical Exam

    well developed, well nourished, in no acute distress.

    Test Management:

    Tests Reviewed:
    BUN: 16 (05/31/2011)
    Creatinine: 0.9 (05/31/2011)
    Sodium: 139 (05/31/2011)
    Potassium: 4.5 (05/31/2011)
    Chloride: 105 (05/31/2011)
    CALCIUM: 9.4 (05/31/2011)
    ANIONGAP: 11 (05/31/2011)
    CO2 Total: 27.2 (05/31/2011)
    GLUCOSE SER: 101 (05/31/2011)
    SGOT (AST): 59 (08/03/2011)
    SGPT (ALT): 74 (08/03/2011)
    PROTEIN, TOT: 7.3 (08/03/2011)
    ALBUMIN: 3.8 (08/03/2011)
    ALK PHOS: 61 (08/03/2011)
    BILI TOTAL: 0.60 (08/03/2011)
    BILI DIRECT: 0.20 (08/03/2011)
    *Anemia view:
    HGB: 10.7 (08/03/2011)
    HCT: 33.4 (08/03/2011)
    MCV: 113.2 (08/03/2011)
    MCH: 36.3 (08/03/2011)
    MCHC: 32.0 G/DL (08/03/2011)
    Platelets: 74 (08/03/2011)

    Impression & Recommendations:

    Problem # 1: HEPATITIS C, CHRONIC VIRAL (ICD-070.54)
    Negative viral load at 24 weeks.

    Plan to recheck CBC in 6 weeks; anticipate resolution of labs to pre-treatment values.

    Recheck viral load in 6 months. Flag made.

    Pt visit today was primarily counseling, coordination and monitoring of potentially lethally toxic chemotherapeutic agents.

    Hemogram (CBC no diff) (HGMP)

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    There's not enough ROS for Comprehensive history, and not enough exam bullets/systems documented for a Comprehensive exam - they'd need one or the other to bill a 99215. I'd go with a 99214 on this. Hope that helps!

  3. #3
    Join Date
    Apr 2007
    Daytona Beach, FL


    If this visit was mainly for counseling, he could have possibly billed a 99215 if he had documented the time.

    The doctor states that "Pt visit today was primarily counseling, coordination and monitoring of potentially lethally toxic chemotherapeutic agents." If he had documented his total time spent (at least 40 minutes for a 99215) with the patient and that more than 50% of this time had been spent in this counseling than he could have billed a 99215. Otherwise, as Brandi stated the History or Exam does not support a Comprehensive level and 99214 would be the highest level he could bill as documented.

    Jodi Dibble, CPC

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