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is this 99215

  1. #1
    Default is this 99215
    Exam Training Packages
    Does this note code to 99215? All responses are appreciated..

    Earache *

    Associated Diagnoses: HTN (Hypertension), Benign; Ear Problems; Rhinitis, allergic; Obesity; Vertigo

    Chief Complaint
    left ear clogged up leading to dizziness

    History of Present Illness
    The patient presents with 35 y/o male here for "clogging" left ear with dizziness and tinnitus. States h/o vertigo. Denies ear pain.

    Also elevated bp. Had recent labs at job in November with glucose, cholesterol which he states were normal. Had elevated bp at work and on 2 occasions here. . Exacerbating factors consist of none. Relieving factors consist of none. Associated symptoms consist of none.

    Review of Systems
    Constitutional: No fatigue.
    Eye: No recent visual problem, No blurring, No double vision, No visual disturbances.
    Respiratory: No shortness of breath.
    Cardiovascular: No chest pain, No palpitations, No peripheral edema, No syncope.
    Gastrointestinal: No nausea, No vomiting, No abdominal pain.
    Genitourinary: No dysuria.
    Integumentary: No other significant skin complaints.
    Neurologic: No headache.
    ROS reviewed as documented in chart

    Health Status

    Allergies: .
    Allergic Reactions (Selected)
    No known allergies

    Medications: (Selected).
    Augmentin 875 mg oral tablet: 1 tab(s), PO, q12hr, # 20 tab(s), 0 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
    Medrol Dosepak 4 mg oral tablet: 1 packet(s), PO, Once, Instructions: as directed on package labeling, # 21 tab(s), 0 Refill(s), Type: Soft Stop, Pharmacy: CVS/pharmacy# 4752
    Ventolin 90 mcg/inh inhalation aerosol: 2 puff(s), INH, QID, PRN: for wheezing, # 1 EA, 0 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752

    Problem list: .
    All Problems (Selected)
    Morbid Obesity / ICD-9-CM 278.01 / Confirmed

    Past Medical History: .
    No active or resolved past medical history items have been selected or recorded.
    Family History: .
    No family history items have been selected or recorded.
    Procedure history: .
    kidney stones in 1900.
    Social History: .
    Alcohol Assessment
    Tobacco Assessment
    Substance Abuse Assessment
    Employment and Education Assessment
    Home and Environment Assessment
    Marital status: Married.

    Physical Examination
    Vital Signs
    Temperature Oral 98.2 DegF
    Peripheral Pulse Rate 76 bpm
    Pulse Site Radial artery
    Respiratory Rate 20 br/min
    Systolic Blood Pressure 146 mmHg HI
    Diastolic Blood Pressure 100 mmHg HI
    Mean Arterial Pressure 115 mmHg
    BP Site Left arm
    Oxygen Saturation 98 %
    , Measurements from flowsheet : Measurements
    Height 68.00 in
    Weight 431.20 lb
    BSA 3.06 m2
    Body Mass Index 65.56 kg/m2

    General: Alert and oriented, No acute distress.
    Eye: Vision unchanged.
    HENT: Normocephalic, Tympanic membranes are clear, Oral mucosa is moist, No pharyngeal erythema, No sinus tenderness, swollen, boggy nasal mucosa.
    Neck: Supple, No carotid bruit, No jugular venous distention, No thyromegaly.
    Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal.
    Cardiovascular: Normal rate, Regular rhythm, No murmur, No gallop, Normal peripheral perfusion, No edema.
    Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.
    Integumentary: Warm, Dry, Pink, No rash.
    Neurologic: Alert, Oriented.
    Psychiatric: Appropriate mood & affect.

    Impression and Plan
    HTN (Hypertension), Benign (ICD9 401.1).
    Rhinitis, allergic (ICD9 477.9).
    Obesity (ICD9 278.00).
    Vertigo (ICD9 780.4).
    Ear Problems (ICD9 V41.3).

    Patient Instructions: Counseled: Patient, Regarding diagnosis, Regarding treatment, Regarding medications, Diet, Activity, Verbalized understanding.
    Summary: Ear problems likely sec. to allergy or vertigo-antivert prn and nasonex. referral to surgery for weight loss consultation. pt to bring copy of recent labs. referral for ophthalmology. spent 40 minutes with pt.

    Charges (Evaluation and Management):
    Return To Office (Requests):
    Return to Clinic (Request) (Ordered): Return in 3 months
    Bystolic 5 mg oral tablet (Ordered): 1 tab(s) ( 5 mg ), po, daily, # 21 tab(s), 0 Refill(s), Type: Maintenance, samples given to patient (Rx)
    Return To Office (Requests):
    Return to Clinic (Request) (Ordered): Return in 2 weeks
    Flonase 0.05 mg/inh nasal spray (Ordered): 1 spray(s), nasal, daily, # 1 EA, 1 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
    Charges (Evaluation and Management):
    99215 office outpt est 40 min level 5 (Charge) (Completed): Quantity: 1

  2. #2
    Evansville Indiana
    In my opinion, the medical necessity is nowhere near a 99215 and you can't bill based on time because it is not documented appropriately.

  3. #3
    Salt Lake City
    the only thing that would support a level 5 here is the exam and thats not enough.

  4. #4
    I agree with Cheermom. I would give this a 99213. No tests were given and the MDM was just not that high. Giving it the distinction of a 99215 would be putting it on the same level as a patient coming in with respiratory distress receiving a chest x-ray and several breathing treatments. Somehow just because the Dr. spent 40 minutes talking with the patient does not seem to warrant bumping up 2 E/M levels.

  5. #5
    Thanks everyone for some push back for doctor on down coding..

    Thanks again

  6. #6
    If you show him the description of the code 99215 he can see where it will state of course
    -Comprehensive history (4 elements)
    -Comprehensice Examination (8 elements)
    -MDM high complexity

    Then comes the description I believe your doctor is getting his 40 minutes from where the AAPC states "Usually, the presenting problem(s) are of moderate to high secerity. Physicians TYPICALLY spend 40 minutes face-to-face with the patient and/or family"

    I usually code ER visits and we often see a patient spend no more than 30 minutes with physician and it be a level 5 (without admission). Also patient would spend up to about an hour with patient and it would be a level 3. Appendix C gives several clinical examples of E & M levels. Incidentally, while scanning the examples, I do not see one where time was mentioned in the example.

  7. #7
    I agree, just because the provider spent 40 minutes with the patient does not justify billing a level 5. There is no documentation of MDM of high complexity, there is no documentation on consuling or coordination of care that would justify the 40 minutes.

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