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Verify Office visit level

  1. Default Verify Office visit level
    Medical Coding Books
    Provider chose a 99213 but I feel this is a 99214. Would like your opinion please.

    Thanks
    Visit Type: Acute Visit
    Primary Provider:

    History of Present Illness:
    pt has been having shortness of breath with great exertion and cold.
    VITAL SIGNS
    Vitals entered by:
    Entered weight: 117 lb.
    Calculated Weight: 117 lb.


    Blood Pressure: 80/60
    Position: Sitting Site: L Arm Cuff: Regular

    Temperature: 96.9 deg F.
    Temp Site: tympanic
    Pulse rate: 88
    Nursing Notes: Asthma Sx - chest hurts, SOB when running in PE, chest hurts when breathing in cold air


    Serial Vital Signs/Assessments:

    PEF PreRx PostRx
    Time O2 Sat O2 Type L/min L/min L/min By
    97 % Room air
    370
    Review of Systems

    General
    Denies fever and chills.

    ENT
    Denies earache, nasal congestion, and sore throat.

    CV
    Denies chest pains.

    Resp
    Complains of cough with exercise.
    Denies nighttime cough or wheeze and wheezing.

    Physical Exam

    General:
    Well appearing child, appropriate for age,no acute distress
    Ears:
    TM's pearly gray with cone, canals clear
    Nose:
    Clear without erythema, edema or exudate
    Mouth:
    Clear without erythema, edema or exudate
    Lungs:
    Clear to ausc, no crackles, rhonchi or wheezing, no grunting, flaring or retractions
    Heart:
    RRR without murmur


    Test Management:

    New Orders:
    1) Ofc Vst, Est Level III (CPT-99213) Due: 01/12/2012

    Impression & Recommendations:

    Problem # 1: ASTHMA, EXERCISE INDUCED (ICD-493.81)
    we had discussion on exercise induced asthma. she/he will start using two puffs of proair one half hour before exercise. she/he will call and let me know how this works for her/him.
    Her/His updated medication list for this problem includes:
    Proair Hfa 108 (90 Base) Mcg/act Aers (Albuterol sulfate) ..... Two puffs half hour before exercises.

    Orders:
    Ofc Vst, Est Level III (CPT-99213)


    Medications Added to Medication List This Visit:
    1) Proair Hfa 108 (90 Base) Mcg/act Aers (Albuterol sulfate) .... Two puffs half hour before exercises.

    Prescriptions:
    PROAIR HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE) two puffs half hour before exercises. #1 x 5
    57250

  2. #2
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    I don't like the EMR as the providers do miss some of the points. I would agree with a 4.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Location
    Columbia, MO
    Posts
    12,531
    Default
    You will need to explain the level 4 I see a clear 3

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    I appears that there was some pt training on the use of medicaitions for the asthma.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  5. #5
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I am not seeing this, I see that it was part of the precrition directions but nothing to indicate there was "pt training", and the exam does not meet detailed criteria.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    Wouldn't you consider the eent detatiled to cc, listening to the breath sounds....chest discomfort can be very serious as I am sure you know, for someone with asthma.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  7. #7
    Location
    Columbia, MO
    Posts
    12,531
    Default
    If they are using 97 guidelines which I used I cannot get a detailed exam given the documentation, it does not matter what I think about the severity or possible severity of the condition , it is what is documented in the exam. I am able to count at most 6 bullets for exam, that is expanded problem focused.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    I will re read the guidelines..We use 1995 at our facility.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  9. #9
    Location
    Columbia, MO
    Posts
    12,531
    Default
    but even for 95 I get only the limited review of the affected body system with related organs which is still expanded focused. Still having problems seeing a 99214.

    Debra A. Mitchell, MSPH, CPC-H

  10. #10
    Location
    Evansville Indiana
    Posts
    451
    Default 99213
    I agree, I can't get enough exam elements for a 99214.
    LeeAnn

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