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Thread: Questionable 99213 level

  1. #1

    Default Questionable 99213 level

    AAPC: Back to School
    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
    Join Date
    Apr 2007

    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

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