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Help what e/m level is this?

  1. #1
    Question Help what e/m level is this?
    Medical Coding Books
    What E/M level is this?
    Thanks


    established patient

    Chief Complaint
    cool clamy skin, abdominal pain, fever at home, hematuria

    History of Present Illness
    Onset this a.m. associated with frequency and dark urine

    Review of Systems
    Gastrointestinal: Nausea, Abdominal pain, Anorexia.
    Genitourinary: No unilateral flank pain.

    Health Status
    Allergies: .
    Allergic Reactions (Selected)
    Severity not Documented
    Iodine (No reactions were documented)
    Medications: (Selected).
    Prescriptions
    Ordered
    Diovan HCT 320 mg-25 mg oral tablet: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH EVERY DAY, # 30 EA, 4 Refill(s), Pharmacy: Walgreens Drug Store 06637
    Klor-Con 10 oral tablet, extended release: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH EVERY DAY, # 30 EA, 4 Refill(s), Pharmacy: Walgreens Drug Store 06637
    Lipitor 10 mg oral tablet: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH EVERY DAY FOR CHOLESTEROL, # 30 tab(s), 2 Refill(s), Pharmacy: Walgreens Drug Store 06637
    METFORMIN 1000MG TABLETS: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH TWICE DAILY FOR DIABETES, # 60 tab(s), 1 Refill(s), Pharmacy: Walgreens Drug Store 06637
    betamethasone-clotrimazole 0.05%-1% topical cream: See Instructions, Instructions: APPLY TO THE AFFECTED AREA OF GENITALIA TWICE DAILY AS NEEDED FOR SKIN IRRITATION, # 45 gm, Pharmacy: Walgreens Drug Store 06637
    glipiZIDE 10 mg oral tablet, extended release: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH TWICE DAILY, # 60 tab(s), 1 Refill(s), Pharmacy: Walgreens Drug Store 06637
    Problem list: .
    All Problems
    Abnormal Chest Sounds / ICD-9-CM 786.7
    Acute Bronchitis / ICD-9-CM 466.0
    Acute Nasopharyngitis [common Cold] / ICD-9-CM 460
    Acute Suppurative Otitis Media without Spontaneous Rupture of Ear Drum / ICD-9-CM 382.00
    Acute Upper Respiratory Infections of Unspecified Site / ICD-9-CM 465.9
    Allergic Rhinitis, Cause Unspecified / ICD-9-CM 477.9
    Benign Essential Hypertension / ICD-9-CM 401.1
    Benign Neoplasm of Skin, Site Unspecified / ICD-9-CM 216.9
    Candidiasis of Skin and Nails / ICD-9-CM 112.3
    Cellulitis and Abscess of Leg, Except Foot / ICD-9-CM 682.6
    Colon Polyps 211.3
    Contact Dermatitis and Other Eczema, Unspecified Cause / ICD-9-CM 692.9
    Contusion of Foot / ICD-9-CM 924.20
    COUGH / ICD-9-CM 786.2
    Dermatophytosis of Groin and Perianal Area / ICD-9-CM 110.3
    Diabetes Mellitus without Mention of Complication, Type II or Unspecified Type, Not Stated as Uncontrolled / ICD-9-CM 250.00
    Diabetes Mellitus without Mention of Complication, Type II or Unspecified Type, Uncontrolled / ICD-9-CM 250.02
    DM Type II no comp. 250.
    EDEMA / ICD-9-CM 782.3
    EPISTAXIS / ICD-9-CM 784.7
    Family History of Diabetes Mellitus / ICD-9-CM V18.0
    Family History of Stroke (Cerebrovascular) / ICD-9-CM V17.1
    HEMATURIA / ICD-9-CM 599.7
    Hyperlipidemia, pure 272
    Hypertension 401.9
    Impacted Cerumen / ICD-9-CM 380.4
    Labyrinthitis, Unspecified / ICD-9-CM 386.30
    LUMBAGO / ICD-9-CM 724.2
    Mixed Hyperlipidemia / ICD-9-CM 272.2
    Mononeuritis of Upper Limb, Unspecified / ICD-9-CM 354.9
    Need for Prophylactic Vaccination and Inoculation Against Influenza / ICD-9-CM V04.81
    Need for Prophylactic Vaccination and Inoculation Against Other Specified Disease / ICD-9-CM V05.8
    Need for Prophylactic Vaccination and Inoculation Against Other Viral Diseases / ICD-9-CM V04.8
    Need for Prophylactic Vaccination and Inoculation Against Tetanus-Diptheria [TD] [DT] / ICD-9-CM V06.5
    Neoplasm of Uncertain Behavior of Skin / ICD-9-CM 238.2
    Obesity / ICD-9-CM 278.00 / Probable
    Obesity / ICD-9-CM 278.00 / Probable
    Open Wound of Multiple Sites, Uncomplicated / ICD-9-CM 873.29
    Osteoarthrosis, Unspecified Whether Generalized or Localized, Involving Lower Leg / ICD-9-CM 715.96
    Other Acute Otitis Externa / ICD-9-CM 380.22
    Other and Unspecified Hyperlipidemia / ICD-9-CM 272.4
    Other Atopic Dermatitis and Related Conditions / ICD-9-CM 691.8
    Other Bursitis Disorders / ICD-9-CM 727.3
    Other Nonspecific Abnormal Findings / ICD-9-CM 796.9
    Other Specific Muscle Disorders / ICD-9-CM 728.3
    Other Specified Hypertrophic and Atrophic Conditions of Skin / ICD-9-CM 701.8
    Pain in Joint Involving Hand / ICD-9-CM 719.44
    Pain in Joint Involving Shoulder Region / ICD-9-CM 719.41
    Personal History of Colonic Polyps / ICD-9-CM V12.72
    Psoriasis and Similar Disorders / ICD-9-CM 696
    ROSACEA / ICD-9-CM 695.3
    Rosacea 695.3
    Screening for Malignant Neoplasms of Colon / ICD-9-CM V76.51
    Screening for Malignant Neoplasms of Prostate / ICD-9-CM V76.44
    Screening for Malignant Neoplasms of Testis / ICD-9-CM V76.45
    Sebaceous Cyst / ICD-9-CM 706.2
    Seborrheic Keratosis / ICD-9-CM 702.1
    Unspecified Disease of Sebaceous Glands / ICD-9-CM 706.9
    Unspecified Disorder of Skin and Subcutaneous Tissue / ICD-9-CM 709.9
    Unspecified Essential Hypertension / ICD-9-CM 401.9
    Unspecified Otitis Media / ICD-9-CM 382.9
    Unspecified Vitamin D Deficiency / ICD-9-CM 268.9
    Urinary Tract Infection, Site Not Specified / ICD-9-CM 599.0
    Venous (Peripheral) Insufficiency, Unspecified / ICD-9-CM 459.81
    Vitamin D deficiency

    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: .
    Hx adenomatous colon polyps in 2004 at 57 Years.
    Colon polypectomy in 1900.
    Fx of L clavicle in 1900.
    Toenail removal in 1900.
    Social History: .
    Alcohol Assessment
    Never
    Tobacco Assessment
    Never
    Substance Abuse Assessment
    Never


    Physical Examination
    VS/Measurements
    Vital Signs
    Temperature Oral 98.0 DegF
    Peripheral Pulse Rate 90 bpm
    Respiratory Rate 24 br/min HI
    Systolic Blood Pressure 126 mmHg
    Diastolic Blood Pressure 68 mmHg
    Mean Arterial Pressure 87 mmHg
    Oxygen Saturation 91 % LOW
    Pain Present Yes (Provider Not Notified)
    , Measurements from flowsheet : Measurements
    Height 72.00 in
    Weight 397.00 lb
    BSA 3.02 m2
    Body Mass Index 53.84 kg/m2

    General: Alert and oriented, Mild distress, Morbidly obese.
    HENT: Mild scleral icterus.
    Respiratory: Lungs are clear to auscultation.
    Cardiovascular: Normal rate, Regular rhythm.
    Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No rebound scars or hernia.
    Neurologic: Alert, Oriented, Normal sensory, Normal motor function.
    Psychiatric: Cooperative, Appropriate mood & affect, Normal judgment.

    Review / Management
    Results review: Lab results.
    Glucose Urine Dipstick Negative
    Bilirubin Urine Dipstick Large
    Ketones Urine Dipstick 1+
    Specific Gravity Urine Dipstick 1.020
    Blood Urine Dipstick Large
    pH Urine Dipstick 5.5
    Protein Urine Dipstick 300 mg/dl
    Urobilinogen Urine Dipstick 1 mg/dl
    Nitrite Urine Dipstick Positive
    Leukocyte Esterase Urine Dipstick Large

    Impression and Plan
    Diagnosis
    Hematuria (ICD9 599.70).
    Jaundice (ICD9 782.4).
    Plan: Referred to the emergency room at for further evaluation differential diagnosis of gallstones pancreatic lesion hepatitis drug effect causing jaundice, Hematuria could be caused by renal stone hemorrhagic cystitis pyelonephritis, Both could be caused by a renal tumor.
    Summary: Because of the possibility of sepsis due to biliary or renal obstruction patient referred to the emergency room.

  2. Default
    looks like 99215

  3. #3
    Default
    99215

  4. #4
    Location
    First Hill, Seattle WA
    Posts
    65
    Default But keep in mind medical necessity
    Just because there's a ton of information in the note, doesn't necessarily mean it's a higher level encounter.

  5. #5
    Smile E/M code
    I would say 99214.

  6. #6
    Default
    99214

    Detailed history, Expanded Problem Focused Exam, Moderate MDM.

    MDM: New problem w workup, Moderate Risk--both meet moderate criteria
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  7. Default
    I say a 99214 also. I agree...EPF History, Detailed History, and Moderate MDM....I didnt count sending the patient to the ER as additional work-up though.

  8. Default
    Also, the providers note of "sepsis" would count in MDM as a High risk. I counted 3 for new problem no additional work-up and 1 for labs in Data Review.

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