Results 1 to 2 of 2

Questionable 99213 level

  1. Default Questionable 99213 level
    Medical Coding Books
    Provider has chosen a 99213

    Visit Type: Acute Visit
    Primary Provider:

    CC: Stomach Pains x 3 weeks, nausea, denies diarrhea, constipation and vomiting, and worse after eating.

    History of Present Illness:
    nausea and cramping abdominal pain ost eating for three weeks. he/she denies any diarrhea opr constipation. he/she denies any fevers. this happens a few minutes post eating. he/she denies any melena. he/she does have a history of reflux.

    Review of Systems
    See HPI

    Vital Signs:

    Patient Profile: 50 Years Old
    Height: 69.5 inches
    Weight: 221 pounds
    Temp: 97.6 degrees F tympanic
    Pulse rate: 72 / minute
    Pulse rhythm: regular
    BP sitting: 118 / 82 (left arm)
    Cuff size: regular

    Vitals Entered By:

    Physical Exam

    well developed, well nourished, in no acute distress.
    diffuse tenderness. normo active bowel tones.

    Impression & Recommendations:

    Problem # 1: GASTRITIS (ICD-535.50)
    will put on protonix.
    His updated medication list for this problem includes:
    Protonix 40 Mg Tbec (Pantoprazole sodium) ..... One tab po daily

    Medications Added to Medication List This Visit:
    1) Protonix 40 Mg Tbec (Pantoprazole sodium) .... One tab po daily

    PROTONIX 40 MG TBEC (PANTOPRAZOLE SODIUM) one tab po daily #30 x 5

  2. #2
    Default Questionable 99213
    I would code this as a 99214 based 1995 CMS documentation guidelines for E/M services

    HPI has 5 elements (only need 4)
    location - stomach
    Quality - cramping
    Duration - x 3 weeks
    Modifying Factors - worse after eating
    Assc. Signs and symptoms - nausea

    ROS has 2 elements
    Constitutional - denies fevers
    GI - denies any melena, diarrhea, constipation and vomiting

    PFSH -
    Past medical history - history of reflux


    EXAM has 2 systems
    Constitutional - vital signs and well developed, well nourished, in no acute distress
    GI - Diffuse tenderness. Normo active bowel tones (since bowel sounds are mentioned this constitutes as a system)


    Medical Decision Making
    New Problem - 3 points
    Amount and/or Complexity - 0 points
    Risk of Complication - Prescription drug managment - moderate

    MDM is Moderate

    Established patient needs 2 out of 3 components - this visit would meet the level of a 99214
    Linda Elley CPC, CPMA, CEMC

Similar Threads

  1. Coding destruction of lesion, questionable malignancy
    By christieanna in forum Dermatology
    Replies: 9
    Last Post: 02-18-2015, 01:04 PM
  2. A questionable directive???
    By jplouffe in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 04-29-2013, 02:30 PM
  3. Questionable hernia repair
    By JenReyn99 in forum General Surgery
    Replies: 1
    Last Post: 07-05-2011, 03:37 PM
  4. stent placement with questionable PTA
    By carriebeth in forum Interventional Radiology
    Replies: 4
    Last Post: 03-26-2010, 12:00 PM
  5. Level 99213??
    By grandmacora in forum E/M
    Replies: 2
    Last Post: 04-24-2009, 06:28 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?


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.