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Level Four (99214)?

  1. #1
    Default Level Four (99214)?
    Medical Coding Books
    Base this on History and MDM.
    What level.

    She is a 56-year old female presenting with a couple of weeks of a heavy sensation in her chest, particularly on work days when she is at work. She works for a dentist. She does yoga and other exercises, which actually relieves her symptoms. She is not having any radiation of pain or respiratory symptoms. She does have a history of hyperlipidmia, however, and is on Zetia.

    She denies any shortness of breath, wheezing, cough, etc.


    Ekg ordered-reviewed: normal sinus rhythm. There is no change from November 2, 2005.


    Assement: Chest tightness, most likely stress-related

    Recommend a trial of Lexapro and continuing with excersise. Will follow up in about three weeks, sooner if her symptoms escalate or they become exertionally-related.

  2. #2
    Default
    Based on HPI and MDM, I would only charge a 99213. The history seems to be expanded problem-focused and the medical decision making seems to fall within the low to moderate range.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  3. #3
    Default
    Quote Originally Posted by daniel View Post
    Base this on History and MDM.
    What level.

    She is a 56-year old female presenting with a couple of weeks of a heavy sensation in her chest, particularly on work days when she is at work. She works for a dentist. She does yoga and other exercises, which actually relieves her symptoms. She is not having any radiation of pain or respiratory symptoms. She does have a history of hyperlipidmia, however, and is on Zetia.

    She denies any shortness of breath, wheezing, cough, etc.


    Ekg ordered-reviewed: normal sinus rhythm. There is no change from November 2, 2005.


    Assement: Chest tightness, most likely stress-related

    Recommend a trial of Lexapro and continuing with excersise. Will follow up in about three weeks, sooner if her symptoms escalate or they become exertionally-related.

    On quick audit I get:
    Duration = 3 weeks
    Quality = "heavy"
    Location = chest
    Context = while at work
    Modifying Factor = Exercising
    Signs/Symptoms = No radiating pain
    ....way to quantify HPI elements!! 4+

    PFSH: Social and Past History Documented - 2/3

    ROS: Respiratory

    History: Expanded Problem Focused

    MDM:
    New problem, no work up
    Data, Review EKG
    Risk - Moderate

    Overall MDM: Moderate

    I tried to squeeze one more ROS, that would have given you you're 99214, but it's not there!!

    So, you've got a 99213

  4. #4
    Default
    Could you use "not having any radiation of pain" as cardiovascular ROS instead of an associated sign/symptom and get an extended ROS?
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

  5. #5
    Default
    I over looked and forgot to add, the M.A. Put in the top of the progress note.
    Medciation allerigies: Demerol.

    So that gives me my Extended ROS. For my four (99214).
    Right.


    Thank For your input

    Daniel,CPC

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