# E&M exam level...HELP PLEASE!!!



## jdd111168 (Mar 5, 2015)

I work for five allergist.  One of my Doctors codes most of his new patient office visits' as a 99204.  By my audits they are 99203 at most.  The Exam portion is what's bringing the level down.  If you were to audit the following what level exam do you get???  I just need to make sure I am not missing anything.  We use 97 Guidelines.  Thank in advance!  

Vitals*3/2/2015 9:24 AM
3/2/2015 9:23 AM
*Weight: 129.8 lb *Height: 60 in
Height was reported by patient.
*Body Surface Area: 1.58 m? *Body Mass Index: 25.35 kg/m?
*Temp.: 98.4? F (Tympanic)* *Pulse: 97 (Regular)* *Resp.: 16 (Unlabored)* *P.OX: 94% (Room air)
*BP: 115/76*** (Sitting, Left Arm, Standard)
*
Physical Exam*
The physical exam findings are as follows:
*
General*
General Appearance*- Cooperative and Well groomed. Posture*- Normal posture. Gait*- Normal. Hydration*- Well hydrated.

Integumentary*
Global Assessment:*Upon inspection and palpation of skin surfaces of the - Head/Face: no rashes, ulcers, lesions or evidence of photo damage. No palpable nodules or masses, Neck: no visible lesions or palpable masses, Right upper extremity: no lesions or rashes. No evidence of photo damage, Left upper extremity: no lesions or rashes. No evidence of photo damage and Distribution of scalp and body hair is normal.
General Characteristics:*Overall examination of the patient's skin reveals* - no rashes. Color*- normal coloration of skin. Skin Moisture*- normal skin moisture. Hair Distribution and Texture - normal distribution of scalp and body hair, with normal hair texture.

Head and Neck
Face*
Global Assessment*- atraumatic.
Neck*
Global Assessment*- supple. non-tender and no lymphadenopathy.
Trachea*- midline.
Thyroid*
Gland Characteristics*- normal size and consistency. non-tender.

Eye*
Eyeball*- Bilateral*- Normal. Sclera/Conjunctiva*- Bilateral*- Normal. Pupil*- Bilateral*- Normal, Equal, Regular and Round. No Fixed.


ENMT
Ears*
Pinna*- Bilateral*- Normal. no edema and no erythema of auricle. External Auditory Canal*- Bilateral*- no cerumen impaction noted, no drainage observed, no edema noted in EAC, no purulent discharge noted and no tenderness noted.
Otoscopic Exam:*Tympanic Membrane*- Bilateral*- no bulging noted, no inflammation observed, no retraction of TM observed, no scarring observed and no evidence of tympanosclerosis.
Nose and Sinuses*
Inspection of the nares - Bilateral*- normal respiration, quiet respiration and no mucus present . Nasal Mucosa*- Bilateral*- no bleeding noted, no congestion observed and no ulcerations observed.
Nasal Septum:*Bony Septum*- no bleeding noted, no inflammation of surrounding mucosa, no perforation noted and no scarring present.
Turbinates:*Inferior*- Bilateral*- not enlarged and no inflammation noted. Maxillary Sinuses*- Bilateral*- no tenderness observed.
Mouth and Throat*
Lips:*Upper Lip*- not dry. Lower Lip*- no dryness observed.
Nasopharynx*- no congestion noted, no discharge present and no mucoid material present in nasopharynx.
Oral Cavity/Oropharynx:*Teeth*- no missing teeth. Gingiva*- no bleeding observed, no hypertrophy noted and no inflammation present. Hard Palate*- no erythema noted, no perforation noted and no petechiae noted. Soft Palate*- no abnormal motion on phonation, no asymmetry noted and no erythema noted. Tongue*- not enlarged, not fissured, no evidence of paralysis and no white patches present. Oral Mucosa*- no discoloration noted and no dryness noted. Oropharynx*- no evidence of airway distress observed, no uvular edema is observed, no edema of posterior pharyngeal walls observed and there is no swelling of the pharyngeal mucosa.
Tonsils:*Characteristics*- Bilateral*- no erythema noted and no hypertrophy.
Floor of Mouth*- no edema observed and no hyperkeratosis observed.

Chest and Lung Exam*
Inspection:*Shape*- Symmetric. Movements*- Symmetrical. Accessory muscles*- No use of accessory muscles in breathing.
Auscultation:*
Breath sounds:*- Normal and - Clear.
Adventitious sounds:*- No Adventitious sounds.

Cardiovascular*
Cardiovascular examination reveals* - normal heart sounds, regular rate and rhythm with no murmurs.

Lymphatic
Head & Neck*
Submandibular Nodes:*
Bilateral:*Size*- Note: no enlarged lymph node* Overlying skin*- Normal.


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## jdibble (Mar 9, 2015)

From what I can see with the exam you posted, your physician would not be able to bill a 99204 as he has not met the requirements for a comprehensive exam under the 1997 guidelines. (he also hasn't met them under the 95 guidelines either). The highest he could bill would be 99203 as this is a detailed exam.

1997 guidelines require documentation of at least 2 bullets in 9 body areas/systems for a comprehensive exam. I can only see 7 areas:
2 bullets - constitutional; 2 - Neck; 2 - eyes; 5 - ENT; 2 - Respiratory; 1 Cardio; 2 - Skin.  There is documentation of 1 lymph node, however according to the requirements to count Lymph he would need to document 2 different body area lymph nodes, so I did not include the Lymph system in my count. 

I am not that familiar with the General System 1997 exam as we always use the 95 guidelines (so much easier to get a comprehensive exam)! So, if someone else finds something that I am missing, I believe you are right that he should not be billed 99204.


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## jdd111168 (Mar 12, 2015)

Thank you Jodi!


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## mdzcpc-i (Apr 29, 2015)

*97 exam question*

Hi Jodi,

if Dr. states "Eyes: normal"
Do you count it?

Appriciate your help. 

Mary D.


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## jdibble (Apr 29, 2015)

Hi Mary,

Yes - if the doctor documents eyes, normal, I would count that towards eyes, however under 97 guidelines I would consider it only 1 bullet. Under 95 guidelines, he would get credit for the entire system. Any finding of normal, the doctor just needs to state normal, however if he documented abnormal, then he would need to elaborate on what his abnormal findings were. Otherwise, if he just stated abnormal and nothing else, then I would not count it.

Hope that helps!


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## mdzcpc-i (Apr 30, 2015)

Jodi, Thank you for clarifying that for me.  I have done it this way for 15 years and was told otherwise by a co-worker.  This is my first time every reaching out to this forum. Thanks again.


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