Results 1 to 2 of 2

?E/M Level

  1. Default ?E/M Level
    Medical Coding Books
    Provider has 99203 but Im only getting a 99202. Advice please

    Visit Type: Acute Visit
    Primary Provider:

    CC: check for STD.

    History of Present Illness:
    pt states here to be checked for STD, HIV

    Had girlfriend/boyfriend who tested positive for gonorrhea. He/she would like to be tested for that and other STDs. He/she thinks that he/she may have some urinary hesitancy and sometimes feels like he/she has a hard time finishing urination.
    No other sx.

    He/She does have hx genital warts-dx 3 years ago.

    Past Medical History:
    Reviewed history and no changes required:
    Healthy

    Past Surgical History:
    Reviewed history and no changes required:
    None

    Family History:
    Reviewed history and no changes required:
    F-DM2

    Social History:
    Reviewed history and no changes required:
    Patient has never smoked.
    Alcohol Use - yes-drinks daily after work--beer or two--some binge drinking.

    Risk Factors:

    Tobacco use: never
    Alcohol use: yes

    Review of Systems
    See HPI

    Vital Signs:

    Patient Profile:
    Weight: 147 pounds
    Temp: 95.6 degrees F tympanic
    Pulse rate: 60 / minute
    Pulse rhythm: regular
    Resp: 18 per minute
    BP sitting: 138 / 80 (left arm)
    Cuff size: large

    Vitals Entered By:


    Physical Exam

    General:
    well developed, well nourished, in no acute distress.
    Lungs:
    clear bilaterally to auscultation.
    Heart:
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
    Psych:
    alert and cooperative; normal mood and affect; normal attention span and concentration.


    Impression & Recommendations:

    Problem # 1: SEXUALLY TRANSMITTED DISEASE, EXPOSURE TO (ICD-V01.6)
    Assessment: New
    Check labs and f/u as indicated.
    Orders:
    HIV1/ HIV2 Antibodies (HIV12)
    Herpes Virus Type II (HERPESII)
    Hepatitis C Ab, Total (HCVAB)
    RPR (RPR)
    Chlamydia & Gonorrhoeae Aptima (APTCG)


    Medications Added to Medication List This Visit:
    1) Allegra Tabs (Fexofenadine hcl tabs)
    2) Nasonex Susp (Mometasone furoate susp)
    3) Qvar Aers (Beclomethasone dipropionate aers)

  2. #2
    Default
    Quote Originally Posted by cnramsey View Post
    Provider has 99203 but Im only getting a 99202. Advice please

    Visit Type: Acute Visit
    Primary Provider:

    CC: check for STD.

    History of Present Illness:
    pt states here to be checked for STD, HIV

    Had girlfriend/boyfriend who tested positive for gonorrhea. He/she would like to be tested for that and other STDs. He/she thinks that he/she may have some urinary hesitancy and sometimes feels like he/she has a hard time finishing urination.
    No other sx.

    He/She does have hx genital warts-dx 3 years ago.

    Past Medical History:
    Reviewed history and no changes required:
    Healthy

    Past Surgical History:
    Reviewed history and no changes required:
    None

    Family History:
    Reviewed history and no changes required:
    F-DM2

    Social History:
    Reviewed history and no changes required:
    Patient has never smoked.
    Alcohol Use - yes-drinks daily after work--beer or two--some binge drinking.

    Risk Factors:

    Tobacco use: never
    Alcohol use: yes

    Review of Systems
    See HPI

    Vital Signs:

    Patient Profile:
    Weight: 147 pounds
    Temp: 95.6 degrees F tympanic
    Pulse rate: 60 / minute
    Pulse rhythm: regular
    Resp: 18 per minute
    BP sitting: 138 / 80 (left arm)
    Cuff size: large

    Vitals Entered By:


    Physical Exam

    General:
    well developed, well nourished, in no acute distress.
    Lungs:
    clear bilaterally to auscultation.
    Heart:
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
    Psych:
    alert and cooperative; normal mood and affect; normal attention span and concentration.


    Impression & Recommendations:

    Problem # 1: SEXUALLY TRANSMITTED DISEASE, EXPOSURE TO (ICD-V01.6)
    Assessment: New
    Check labs and f/u as indicated.
    Orders:
    HIV1/ HIV2 Antibodies (HIV12)
    Herpes Virus Type II (HERPESII)
    Hepatitis C Ab, Total (HCVAB)
    RPR (RPR)
    Chlamydia & Gonorrhoeae Aptima (APTCG)


    Medications Added to Medication List This Visit:
    1) Allegra Tabs (Fexofenadine hcl tabs)
    2) Nasonex Susp (Mometasone furoate susp)
    3) Qvar Aers (Beclomethasone dipropionate aers)
    For a 99203, you must have all of the following, at minimum:
    Detailed History (4 HPI, >2 ROS, >1 area PFSH)
    Detailed exam (>2 body areas/organ systems - 1995, or 12 bullets - 1997)
    Low MDM (Best 2/3: >2 points in diagnoses/management options, >2 points in data reviewed, and/or Low risk)

    Right off the bat, I see several HPI:
    Had girlfriend/boyfriend who tested positive for gonorrhea. (HPI Context)
    He/she thinks that he/she may have some urinary hesitancy (HPI Associated signs/symptoms, or ROS: Genitourinary - since the doctor didn't document a separate ROS, you've got to take it from somewhere, so this statement would probably be best)
    and sometimes feels like he/she has a hard time finishing urination. ("sometimes" = timing, "has a hard time finishing urination" = quality, or possibly severity, depending on how you look at it)
    No other sx.
    He/She does have hx genital warts-dx 3 years ago.
    (Personal History)

    You've also got some additional family and social history, so the PFSH is not in question. According to Deborah Grider, a single statement can't be counted as both HPI and ROS, but that's a point of contention amongst auditors, so it's considered 'debatable', to some. I think that it's a bit of a moot point, here, because you don't have enough ROS to be considered "extended" in the first place, so the encounter would be disqualified for a 99203 based on that. He made no mention of specific symptoms, aside from the genitourinary system. "No other sx" is too vague to indicate that ROS was performed on any other systems. Had he stated "All other systems negative for symptoms", then it would have been counted as complete, but documentation guidelines are very clear on making that distinction, so your provider may want to reconsider the way that he words things, in the future. Genital warts are not a current problem, and without mentioning the presence or absence of a current outbreak, I wouldn't count it as anything more than personal history.

    As for the exam - you can reach detailed by 1995 guidelines, since 2-7 body areas/organ systems are all that's required, but you're nowhere near 12 bullets if he's following 97 rules. In fact, there are barely enough there to qualify for an EPF exam, if you're counting bullets.

    MDM is easily low - 1 point under Dx/treatment options (either 1 point for # of diagnoses, or 1 point for the Rx drug management)
    2 points for data (>4 labs ordered for a single problem)
    Moderate risk (Rx drugs)

    So, I agree with the 99202, because the documentation was kind of shoddy. I noticed the prescriptions at the bottom, which appear to be for allergies - there's absolutely no mention of them in the history or exam, so the provider missed an opportunity to qualify for a higher level of E/M there, too. You can only code what he wrote down, so if he wants to get paid for all of his work, he should make it a point to document all of it. Hope that helps!
    Last edited by btadlock1; 08-26-2011 at 12:57 AM.

Similar Threads

  1. Replies: 0
    Last Post: 01-28-2013, 09:52 PM
  2. Level 1 and Level II Remote Coder Positions
    By gfrancis in forum Job Postings
    Replies: 2
    Last Post: 05-31-2012, 10:05 PM
  3. 2 Level decompression, 1 new level, 1 redo
    By mbabou in forum Orthopaedics
    Replies: 1
    Last Post: 02-10-2010, 01:36 PM
  4. H&P performed with level 3 visit, raise level 4?
    By LynnS.321 in forum Orthopaedics
    Replies: 1
    Last Post: 10-23-2009, 07:28 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.