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Thread: is this 99215

  1. #1
    Join Date
    Apr 2007
    Location
    New Orleans
    Posts
    297

    Default is this 99215

    Promo: Code Books
    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).
    Prescriptions
    Ordered
    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

    Histories
    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
    Never
    Tobacco Assessment
    Never
    Substance Abuse Assessment
    Never
    Employment and Education Assessment
    Employed
    Home and Environment Assessment
    Marital status: Married.

    Physical Examination
    VS/Measurements
    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
    Diagnosis
    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.
    Orders


    Charges (Evaluation and Management):
    Return To Office (Requests):
    Return to Clinic (Request) (Ordered): Return in 3 months
    Orders.
    Pharmacy:
    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
    Orders.
    Pharmacy:
    Flonase 0.05 mg/inh nasal spray (Ordered): 1 spray(s), nasal, daily, # 1 EA, 1 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
    Orders.
    Charges (Evaluation and Management):
    99215 office outpt est 40 min level 5 (Charge) (Completed): Quantity: 1

  2. #2
    Join Date
    Apr 2007
    Location
    Evansville Indiana
    Posts
    451

    Default

    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.
    LeeAnn

  3. #3
    Join Date
    Apr 2007
    Location
    Salt Lake City
    Posts
    841

    Default

    the only thing that would support a level 5 here is the exam and thats not enough.
    Jenifer McPolin CPC, CPMA, RCC

  4. #4
    Join Date
    Apr 2007
    Posts
    73

    Default

    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
    Join Date
    Apr 2007
    Location
    New Orleans
    Posts
    297

    Default

    Thanks everyone for responding...got some push back for doctor on down coding..

    Thanks again

  6. #6
    Join Date
    Apr 2007
    Posts
    73

    Default

    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
    Join Date
    Apr 2007
    Location
    San Antonio, TX
    Posts
    173

    Default

    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.
    EVELYN KIM , MBA, CPC, CRC
    Revenue Cycle Supervisor

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