Results 1 to 10 of 10

Audit question

  1. #1
    Default Audit question
    Medical Coding Books
    How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


    Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.

    CURRENT MEDICATIONS:
    1. Altace 10 mg b.i.d.
    2. Amiodarone 200 mg q.d.
    3. Coumadin sliding scale.
    4. Coreg CR 40 mg q.d.
    5. Torsemide 20 mg q.o.d.
    6. Repliva q 3 days.
    7. Flomax .4 mg q.o.d.

    PHYSICAL EXAMINATION:
    Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.

    LABORATORY DATA:
    Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.

    ASSESSMENT:
    1. Acute renal failure, revolved. Renal function back to baseline.
    2. Vitamin D deficiency with mild hyperparathyroidism.
    3. Good blood pressure and volume control.
    4. ALLERGY TO SULFA.
    5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.

    PLAN:
    1. We put him on 800 IU of vitamin D q.d.
    2. We didn't change any other medications.
    3. Return in 6 months.
    4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.

  2. #2
    Default
    Absolutely, I'd bill it a 99214. Here's why...

    On quick audit, I credit:
    EPF history
    (1 cc reviewed, minimal HPI--more past history), 3 ROS (CV-chest pain, Resp-"shortness of air" taken from exam, but are ROS items, GU), Past history (meds, operations, hospitalizations)

    Comprehensive Exam (95 DGs)

    (8+ BA/OS: head, eyes, ENMT (HEENT), constitutional (vitals), CV, Resp, GI, skin, psych (alert, oriented X3)

    MDM of moderate decision making
    (3-4 established dx--per assessment--number of diags/treatment options, review of labs, and two or more stable, chronic illnesses per the table of risk)

    2 out of three makes this a 99214

    Agree?



    Quote Originally Posted by abill_423 View Post
    How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


    Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.

    CURRENT MEDICATIONS:
    1. Altace 10 mg b.i.d.
    2. Amiodarone 200 mg q.d.
    3. Coumadin sliding scale.
    4. Coreg CR 40 mg q.d.
    5. Torsemide 20 mg q.o.d.
    6. Repliva q 3 days.
    7. Flomax .4 mg q.o.d.

    PHYSICAL EXAMINATION:
    Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.

    LABORATORY DATA:
    Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.

    ASSESSMENT:
    1. Acute renal failure, revolved. Renal function back to baseline.
    2. Vitamin D deficiency with mild hyperparathyroidism.
    3. Good blood pressure and volume control.
    4. ALLERGY TO SULFA.
    5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.

    PLAN:
    1. We put him on 800 IU of vitamin D q.d.
    2. We didn't change any other medications.
    3. Return in 6 months.
    4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.

  3. #3
    Default
    Quote Originally Posted by abill_423 View Post
    How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


    Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.

    CURRENT MEDICATIONS:
    1. Altace 10 mg b.i.d.
    2. Amiodarone 200 mg q.d.
    3. Coumadin sliding scale.
    4. Coreg CR 40 mg q.d.
    5. Torsemide 20 mg q.o.d.
    6. Repliva q 3 days.
    7. Flomax .4 mg q.o.d.

    PHYSICAL EXAMINATION:
    Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.

    LABORATORY DATA:
    Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.

    ASSESSMENT:
    1. Acute renal failure, revolved. Renal function back to baseline.
    2. Vitamin D deficiency with mild hyperparathyroidism.
    3. Good blood pressure and volume control.
    4. ALLERGY TO SULFA.
    5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.

    PLAN:
    1. We put him on 800 IU of vitamin D q.d.
    2. We didn’t change any other medications.
    3. Return in 6 months.
    4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.
    I would use the exam and medical decision making:

    1995, I get Comprehensive (8 organ systems) - constitutional, psych, cv, resp, gastro, musculo, skin, enmt

    1997, I get Expanded Problem Focused: 1 bullet gen appear, 2 bullet psych, 3 bullet 3/7 vitals, 4 bullet ausc lungs, 5 bullet ausc heart, 6 bullet exam of abd, 7 bullet extrem for edema, 8 bullet skin exam

    Medical Decision Making:
    2+Est prob, stable
    new prob, no work up (Vit D def)
    total 4+ points

    Order Labs 1 point

    Risk: rx drug management (vit d) or 2 stable chronic illnesses

    MDM - Moderate

    Level: 99214 - i agree
    Last edited by ARCPC9491; 09-23-2008 at 11:29 AM.

  4. #4
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    I agree! It is a 99214!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  5. #5
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    WOW ! well - I agree with the doc - I'd call it a level 2 - here's my reasoning -
    I get a Problem Focused History (appears the patient is in for a follow up of his recent issue and hospital stay - basically a lot of "previous medical history" given there in the first paragraph and not a whole lot of HPI). ROS - I get "none" or 1-constitutional if I pull it from the exam, which really doesn't matter because - my HPI is still lowest at "problem focused". PFSH - I have Detailed "previous medical" ...as I stated, the first paragraph covers that. SO - all in all - HISTORY COMPONENT is "PROBLEM FOCUSED HISTORY".
    EXAM - I pull everything out of it rather than putting the constitutioanl in the ROS - and I get a COMPREHENSIVE EXAM.
    MDM - I get STRAIGHT FORWARD - Established problem to examiner, labs yes, and low to moderate complication risk - either way - the MDM = STRAIGHT FORWARD
    so -
    HISTORY = PF
    EXAM = COMP
    MDM =SF
    2 of 3 elements met which brings it down to the 99212. In my opinion, the doc knew this was a follow up and chose his level accordingly. Though the exam was "comprehensive", the rest of the visit was limited.
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  6. #6
    Default
    I agree w/ Donna. I don't see a 4 either. I get a 3 instead.
    Vit D is an over the counter Drug = low risk not moderate.
    adrianne, cpc

  7. #7
    Default
    Here's my reasoning for MDM...

    Problem Points:
    Stage III Chronic Kidney Disease, Stable = 1 point
    Nephrosclerosis, Stable = 1 point
    (you do get credit for more than 1 est stable prob, with a max of 2)
    Vit D Deficiency w/ mild hyperparathyroidism, New problem(s)
    ..and we can stop there, b/c we've maxed out our problem points, exceeding 4+

    Labs, 1 data point

    Stage III Chronic Kidney Disease, Nephrosclerosis (2 chronic conditions, stable) Moderate Risk

    (Vitamin D can be rx. At a glance I thought under Plan, it said: No other changes made to prescriptions, but after re-reading, it said medications and given the dosage, it can be bought OTC. Bad judgement on my end to use in this case)
    Last edited by ARCPC9491; 09-24-2008 at 09:00 AM.

  8. #8
    Default
    but the renal failure is back to normal. Documentation states that his last attack was acute and now longer applys, either way this pt has normal renal function. Where's the dx in that, it's resolved.
    adrianne, cpc

  9. #9
    Default
    abenson,
    I'm not using the 'acute renal failure' in my medical decision making. I understand that it's resolved - but resolved or not, a patient can still have chronic kidney disease and acute renal failure at the same time - the acuity and failure to his kidneys may no longer be a threat at this time - but the CKD still exists.

  10. Talking
    i stand corrected
    adrianne, cpc

Similar Threads

  1. Audit question
    By *Mel* in forum Auditing General Discussion
    Replies: 0
    Last Post: 07-24-2015, 01:25 PM
  2. audit question
    By camilleb in forum E/M
    Replies: 2
    Last Post: 02-26-2014, 02:20 PM
  3. Replies: 3
    Last Post: 09-30-2011, 09:59 AM
  4. Replies: 4
    Last Post: 10-02-2009, 11:52 AM
  5. E/M audit question
    By meganpoelzer in forum E/M
    Replies: 7
    Last Post: 12-05-2008, 10:08 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.