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1995 guidelines

  1. #1
    Default 1995 guidelines
    Medical Coding Books

    how far is it true that while using 1995 guidelines ,just writing normal for examination is ok

    eg:- respiratory system - normal
    respirtory system -lungs clear,vesicular breathing

    dia - tonsillitis

    res -normal
    ent -throat congested
    gi -normal
    skin -normal

    mdm -moderate

    physician want me to give 99214 .i think this examination is not sufficient.

    your valuable advices are welcome.


  2. #2
    Ellenville, New York
    Default At best, an EPF exam
    I wouldn't use a detailed exam for this as there wasn't much done on each system - since these are brief descriptions, I believe the best you can do is EPF given this documentation.

    However, 99214 may not be completely ruled out, as if there is detailed or comprehensive history and MDM of moderate or high level, that would meet the 2 of 3 requirement for an established patient.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

  3. #3
    Concord, NC or Rochester, NY
    for a detailed exam using 95 guidelines, you need to have one system that is examined in more detail. I do not see any system that is examined in more detail so the exam part of the visit would not qualify as detailed.

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