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so, what level do you come up with?

  1. #1
    Location
    Duluth, Minnesota
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    Default so, what level do you come up with?
    Medical Coding Books
    Below is an E/M visit that I had to audit and score out. If anyone has the time to score this out and let me know what they come up with (and how) I'd sure appreciate it. It is the exact note I reviewed to determine my level. This documentation has become the hot topic around here as far as what level it is, and why. I'll be bringing this note and my scoring E/M sheet to an E/M training class on August 28th. It will be interesting to see what they think too! Thanks for any input you have! I realize you'll probably have a few questions right off the bat, but please (that's part of my point), just work with what is written below. THANKS TONS!
    SUBJECTIVE: Patient comes today with complaints of stabbing right ear pain and some sinus pain and pressure. He feels that this ear pain is constant over the past few days. He complains that he has had an ear infection two times for the past few years. He has tried over the counter Excedrin for the pain and he does get some relief from this. In the past for his sinuses he has tried nasal saline spray, has not done this on any consistent basis. He has had no fever, rhinorrhea or cough. He has had these symptoms on and off for the past month but worse in the last few days. He reports that he is normally healthy. No chronic diseases such as diabetes, heart, lung or kidney problems. Diabetes does run in his family and 20 years ago he passed out from hypoglycemia so he does make it a point to eat small frequent meals so this does not happen again. He has not had a routine physical in 3-5 years.

    Routine medications: Multivitamin.

    Allergies: No known medication allergies.

    Risk factors: Smokes two packs per day for 37 years. Is contemplating quitting. Has quit in the past for as long as six months. This was a couple years ago. His wife is a smoker, she refused to smoke outside of the house. This made it difficult for him while he was attempting to quit and he subsequently resumed smoking again.

    OBJECTIVE: Vital signs: Weight 218.6#, Height 58", Blood pressure 124/78, Temp 97.6, Pulse 76, Respirations 20.
    Constitutional: Pleasant, alert and oriented X3, forty-two year old white male in no acute distress.
    HEENT:
    Head: Atraumatic, normocephalic.
    Eyes: Sclerae clear, conjunctivae non injected. No drainage, no eyelid inflammation or swelling. Pupils equal, round and reactive to light and accommodation. Funduscopic exam essentially within normal limits.
    Ears: External auditory canals patent. Tympanic membranes pearly gray, bony landmarks visualized. Light reflex intact and clear fluid noted behind the tympanic membranes.
    Nose: Nasal mucosa erythematous with brown discoloration from nicotine. Swollen pharynx posterior mildly injected worse on the right. Tonsils non swollen no exudates. Uvula rises midline. Swallowing intact.
    Neck: Supple, full range of motion, no lymphadenopathy.
    Sinuses: Non tender to palpation, frontal and maxillary. No periorbital swelling. No facial swelling or erythema.

    ASSESSMENT: 1) Eustachian tube dysfunction.
    2) Pharyngitis.
    3) Nasal congestion.
    4) Tobacco addiction.

    PLAN: Discussion with patient that the best way to improve his symptoms overall is for him to quit smoking. This was discussed with patient, he has been contemplating trying to quit and was pleased with his prior success. Has considered using Chantix. Risks and benefits of this was discussed today, a prescription was written for a starter pack with two refills. Would have him do symptomatic measures for the sore throat, including warm salt water gargles, ibuprofen or Tylenol as needed. For his nasal congestion would have him use Afrin nasal spray for no more than three days. Was cautioned regarding rebound congestion if he used this for longer than three days. Was also given a nasal steroid. Have him use the Afrin first, then wait an hour and use the nasal steroid. If the nasal steroid spray is helping him following a week and a half use he can continue using this two puffs each nostril everyday. If it is not helping, he should stop it. He verbalizes understanding and agreement with plan. Would also recommend that he follow up for routine preventative health maintenance.
    Donna, CPC, CPC-H

  2. #2
    Location
    Greeley, Colorado
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    Donna - I was not clear if this was an established or new patient... For established I came up with 99214 (detailed history and exam, and moderate MDM); for new I came up with 99203.

    What did you get and what is the controversy?
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Location
    Duluth, Minnesota
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    thanks Lisa - yes, not knowing new/est was part of the problem. Patient is new - I came up with 99214 also for est but 99202 for new. I have EPF History - DET Exam - MOD MDM.

    oops - sorry (I have two issue E/M's that I'm working on) on this one, not knowing new or est was part of the problem- I acutally got EPF History and Exam (not detailed exam on this one) - and MDM MOD.
    so, really - I got a 99213 est and 99202 new for this posted E/M visit.

    the issue was it was first coded as an established patient (coded from the note only). Provider then let us know it was a new patient - and she wanted it a 99203, I come up with 99202.
    HPI x3- Pain - ear/sinus, duration, modifying factor
    ROS x1- Allergy
    PFSH x2- Previous Medical - Family
    For Exam - I have Const, neck, eyes, ENT mouth -
    MDM - moderate (new problem w/prescription)

    so, are you getting more of an HPI and EXAM? are you using the "negative" responses for under your HPI? Even getting the HPI up to detail, (using negative associated signs/symptoms) or the ROS 2-9 systems (using negatives cough/rhinorrhea) - I can see where those can go higher - but I still don't see a Detailed Exam (which brings the new patient down to a 99202) what did you get for your EXAM?
    thanks again!
    Last edited by dmaec; 08-11-2008 at 02:27 PM.
    Donna, CPC, CPC-H

  4. #4
    Location
    Greeley, Colorado
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    For the HPI I have location (ear), quality (stabbing pain), timing (constant), duration (past few days); ROS I have constitutional (no fever) and ENT (no rhinorrhea or cough) - pertinent negatives; PFSH I have past hx (no chronic diseases/also that he has had ear inf twice in the past few years); family hx (diabetes not running in the family); social - smoker.

    Exam I scored 4 organ systems = detailed because of the detailed nature of the ENT exam.
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Location
    Milwaukee WI
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    4,466
    Default History
    Donna,
    When I look at the History I marked "new" because the MD states - no physicial in 3-5 years. I guess I was assuming ... bad sign .. (at least I assumed correctly, this time) ... LOL

    Okay ... seems like history is your main problem/controversy ...
    Here's what I get:
    Chief complaint: ear and sinus pain
    HPI: Location (right ear), Quality (stabbing pain), Timing (constant), Duration (several days), Modifying factors (Excedrin w/ some relief)

    Everything else I count towards ROS ... and they're all negative:
    fever, rhinorrhea, cough, diabetes (endocrine), heart, lung, kidney, allergy

    Family history of DM
    Past med history: hypoglycemia
    Social history: pt is smoker and wife smokes

    I'd get 99203

    F Tessa Bartels, CPC, CPC-E/M

  6. #6
    Location
    Duluth, Minnesota
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    Default
    thanks FTessaBartels - I'd agree I can get my HPI and ROS a bit more detailed - but how do you get a detailed exam? What are you marking for that?
    It seems my exam component is what's lacking, and I'm having difficulty pulling a detailed with only 2-4 systems... Const/neck/Eyes/ENT

    what am I missing!
    thanks!
    Donna, CPC, CPC-H

  7. #7
    Location
    Duluth, Minnesota
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    ohh..and I totally missed the "quality" stabbing pain... *sighs*... correct on all 3 PFSH - (but even 2 gives me the complete). I put the negatives under the ROS also, but still that's just equals a Detailed History - EXP Exam and MOD MDM - which is still a 99202 new patient.
    Donna, CPC, CPC-H

  8. #8
    Location
    Duluth, Minnesota
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    Quote Originally Posted by Lisa Curtis View Post
    For the HPI I have location (ear), quality (stabbing pain), timing (constant), duration (past few days); ROS I have constitutional (no fever) and ENT (no rhinorrhea or cough) - pertinent negatives; PFSH I have past hx (no chronic diseases/also that he has had ear inf twice in the past few years); family hx (diabetes not running in the family); social - smoker.

    Exam I scored 4 organ systems = detailed because of the detailed nature of the ENT exam.
    we must use different tools - my EXAM Component 2-4 systems including affected area is only equal to a Expanded Problem Focused.
    hmmm.....
    Donna, CPC, CPC-H

  9. #9
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    Greeley, Colorado
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    Quote Originally Posted by dmaec View Post
    ohh..and I totally missed the "quality" stabbing pain... *sighs*... correct on all 3 PFSH - (but even 2 gives me the complete). I put the negatives under the ROS also, but still that's just equals a Detailed History - EXP Exam and MOD MDM - which is still a 99202 new patient.
    Remember that 95 guidelines allow for 2-7 systems for EPF and Detailed. I went detailed because of the detailed nature of the ENT exam...following 95 guidelines.
    Lisa Bledsoe, CPC, CPMA

  10. #10
    Location
    Milwaukee WI
    Posts
    4,466
    Default 1995 guidelines
    Yes, I also was using 1995 guidelines for this one.

    GREAT question/ scenario, Donna!

    F Tessa Bartels, CPC, CPC-E/M

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