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Verify office visit level

  1. Default Verify office visit level
    Medical Coding Books
    Just double check this level. Provider has 99213 but I'm getting 99214. Just need a second opinion please. Thanks

    Primary Provider:

    CC: Diabetic ck , meds and , and cough.

    History of Present Illness:
    2 weeks of cough that is very harsh, thick phlegm, feels miserable. nasal drainage. no fever or chills.

    blood sugars stable -fasting s 100-120 . no neuropathy.

    smoker.

    Vital Signs:

    Patient Profile: Years Old
    Height: 67 inches
    Weight: 160 pounds
    BMI: 25.15
    BSA: 1.84
    Temp: 96.1 degrees F tympanic
    Pulse rate: 74 / minute
    Pulse rhythm: regular
    BP sitting: 120 / 70 (left arm)
    Cuff size: regular

    Vitals Entered By:

    Physical Exam

    General:
    well developed, well nourished, in no acute distress.
    Ears:
    TM's intact and clear with normal canals with grossly normal hearing.
    Nose:
    red, irritated nares
    Neck:
    no masses, thyromegaly, or abnormal cervical nodes.
    Lungs:
    rhonci on left. no wheeze
    Heart:
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
    Extremities:
    trace edema
    varicosities
    Neurologic:
    monfilament exam positive x 8.


    Impression & Recommendations:

    Problem # 1: PNEUMONIA (ICD-486)
    clinically suspected pneumonia. hx of same
    start levaquin. check inr on monday given interaction of quinolones with coumadin
    f/u if not improving
    Orders:
    Hemogram (CBC no diff) (HGMP)

    Her/His updated medication list for this problem includes:
    Levaquin 500 Mg Tabs (Levofloxacin) ..... 1 po daily


    Problem # 2: DIABETES MELLITUS, TYPE II, CONTROLLED (ICD-250.00)
    blood sugars in good control. avandia to be pulled from market and will plan on going to lantus at that time
    recheck a1c
    Her/His updated medication list for this problem includes:
    Enalapril Maleate 10 Mg Tabs (Enalapril maleate) ..... 1 po qd
    Glucophage 1000 Mg Tabs (Metformin hcl) ..... 1 po bid
    Avandia Tabs (Rosiglitazone maleate tabs) ..... Avandia 4 mg po qd

    Orders:
    Comprehensive Metabolic Panel (CMP)
    Glycohemoglobin (GLHGB)


    Problem # 3: HYPERLIPIDEMIA (ICD-272.4)
    recheck lipids
    Her/His updated medication list for this problem includes:
    Gemfibrozil 600 Mg Tabs (Gemfibrozil) ..... One tab po bid

    Orders:
    Comprehensive Metabolic Panel (CMP)
    Lipid Panel (9-12 Hour Fast) (LP)


    Problem # 4: ATRIAL FIBRILLATION (ICD-427.31)
    rate controlled
    Her/His updated medication list for this problem includes:
    Coumadin 5 Mg Tabs (Warfarin sodium) ..... One po tues - thurs- friday- sat-sun
    Lanoxin 0.25 Mg Tabs (Digoxin) ..... 1 po qd
    Warfarin Sodium 7.5 Mg Tabs (Warfarin sodium) ..... One po mon and wed


    Medications Added to Medication List This Visit:
    1) Levaquin 500 Mg Tabs (Levofloxacin) .... 1 po daily

    Prescriptions:
    LEVAQUIN 500 MG TABS (LEVOFLOXACIN)

  2. Default
    Quote Originally Posted by cnramsey View Post
    Just double check this level. Provider has 99213 but I'm getting 99214. Just need a second opinion please. Thanks

    Primary Provider:

    CC: Diabetic ck , meds and , and cough.

    History of Present Illness:
    2 weeks of cough that is very harsh, thick phlegm, feels miserable. nasal drainage. no fever or chills.

    blood sugars stable -fasting s 100-120 . no neuropathy.

    smoker.

    Vital Signs:

    Patient Profile: Years Old
    Height: 67 inches
    Weight: 160 pounds
    BMI: 25.15
    BSA: 1.84
    Temp: 96.1 degrees F tympanic
    Pulse rate: 74 / minute
    Pulse rhythm: regular
    BP sitting: 120 / 70 (left arm)
    Cuff size: regular

    Vitals Entered By:

    Physical Exam

    General:
    well developed, well nourished, in no acute distress.
    Ears:
    TM's intact and clear with normal canals with grossly normal hearing.
    Nose:
    red, irritated nares
    Neck:
    no masses, thyromegaly, or abnormal cervical nodes.
    Lungs:
    rhonci on left. no wheeze
    Heart:
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
    Extremities:
    trace edema
    varicosities
    Neurologic:
    monfilament exam positive x 8.


    Impression & Recommendations:

    Problem # 1: PNEUMONIA (ICD-486)
    clinically suspected pneumonia. hx of same
    start levaquin. check inr on monday given interaction of quinolones with coumadin
    f/u if not improving
    Orders:
    Hemogram (CBC no diff) (HGMP)

    Her/His updated medication list for this problem includes:
    Levaquin 500 Mg Tabs (Levofloxacin) ..... 1 po daily


    Problem # 2: DIABETES MELLITUS, TYPE II, CONTROLLED (ICD-250.00)
    blood sugars in good control. avandia to be pulled from market and will plan on going to lantus at that time
    recheck a1c
    Her/His updated medication list for this problem includes:
    Enalapril Maleate 10 Mg Tabs (Enalapril maleate) ..... 1 po qd
    Glucophage 1000 Mg Tabs (Metformin hcl) ..... 1 po bid
    Avandia Tabs (Rosiglitazone maleate tabs) ..... Avandia 4 mg po qd

    Orders:
    Comprehensive Metabolic Panel (CMP)
    Glycohemoglobin (GLHGB)


    Problem # 3: HYPERLIPIDEMIA (ICD-272.4)
    recheck lipids
    Her/His updated medication list for this problem includes:
    Gemfibrozil 600 Mg Tabs (Gemfibrozil) ..... One tab po bid

    Orders:
    Comprehensive Metabolic Panel (CMP)
    Lipid Panel (9-12 Hour Fast) (LP)


    Problem # 4: ATRIAL FIBRILLATION (ICD-427.31)
    rate controlled
    Her/His updated medication list for this problem includes:
    Coumadin 5 Mg Tabs (Warfarin sodium) ..... One po tues - thurs- friday- sat-sun
    Lanoxin 0.25 Mg Tabs (Digoxin) ..... 1 po qd
    Warfarin Sodium 7.5 Mg Tabs (Warfarin sodium) ..... One po mon and wed


    Medications Added to Medication List This Visit:
    1) Levaquin 500 Mg Tabs (Levofloxacin) .... 1 po daily

    Prescriptions:
    LEVAQUIN 500 MG TABS (LEVOFLOXACIN)
    I clearly get 99214

    Exam: Detailed 95'

    MDM

    Problem pts: 4+
    Level of risk: Moderate - Prescription drug management or one or more chronic illnesses w/ mild exacerbation
    Work up pts: 1
    _______________
    Moderate MDM

    Those components togther (exam + MDM) = 99214 in my opinion..

  3. #3
    Location
    Salt Lake City
    Posts
    841
    Default
    Yes I would say 99214 based on the exam and MDM
    Jenifer McPolin CPC, CPMA, RCC

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