# 99215?



## lynnmc79 (Sep 28, 2010)

I have two examples of dictation for a patient my doctor insists that these are both level 99215 but I don't see how. Need some help please. 
1st example is this:
DIAG:  Diffuse large B cell lymphoma, Stage IIIB (E,S).
TREATMENT:  S/P two cycles Rituxan/CHOP today.
IH:  Mr. doe presents for follow-up of lymphoma.  He is tolerating chemotherapy without difficulty.  However, he has become increasingly depressed.  His appetite is poor.  He says that food does not taste good.  His wife is concerned because Mr. doe spends most of his time on the couch or on the computer.  He has very little motivation to do much else.  Mr. doe says that he is not limited by weakness or any physical ailment, he simply does not have the mental desire to do much at this point in time.  He is admittedly depressed and expresses concern over his medical bills.  He has an ECOG PS of 2.
ROS:  As per Interval History;  all others are negative in detail.
PE:  Temp.  97.2.  BP 132/70.  P 70.  R 16.  Heart:  Regular rate and rhythm.  Lungs are clear to auscultation bilaterally.  Abdomen soft, non-tender, non-distended, with normoactive bowel sounds.  No palpable hepatosplenomegaly.    Extremities without cyanosis, clubbing, or edema.  Neuro exam is non-focal.
LABS:  WBC 11.3.  HGB 11.9.  HCT 35.1.  PLT 319.
ASSESSMENT:  63-year-old white male with diffuse large B cell lymphoma.  S/P two cycles of Rituxan/CHOP.  He has had an excellent response to therapy.  He had a long treatment delay between cycles 1 and 2, secondary to development of intracranial bleed requiring craniotomy x3.  Remarkably, the patient has made near complete recovery from this.
PLAN:
1.	Cycle 3, Day 1 Rituxan/CHOP today.
2.	Continue Lexapro for depression.
3.	Megace ES, 1 t. daily for appetite stimulation.
4.	O/V three weeks for follow-up.
5.	CT for restaging after Cycle 4 of therapy.

2nd example is this:
DIAG:  Diffuse large B cell lymphoma, Stage IIIB (E,S).
TREATMENT:  Cycle 2, Day 1 Rituxan/CHOP today.
IH:  Mr. doe presents for follow-up of lymphoma.  He is scheduled to restart chemotherapy at this point in time.  He is feeling well.  He still has some residual weakness from deconditioning related to his protracted hospitalization, as described on prior dictations.  He has not had any headaches.  He denies fevers, chills, or night sweats.
ROS:  As per Interval History;  all others are negative in detail.
PE:  Temp.  97.0.  BP 154/82.  P 78.  R 16.  Heart:  Regular rate and rhythm.  Lungs are clear to auscultation bilaterally.  Abdomen soft, non-tender, non-distended, with normoactive bowel sounds.  No palpable hepatosplenomegaly.    Extremities without cyanosis, clubbing, or edema.  Neuro exam is non-focal.
LABS:  WBC 7.0.  HGB 11.6.  HCT 34.4.  PLT 285.
ASSESSMENT:  63-year-old white male with diffuse large B cell lymphoma.
PLAN:  Cycle 2, Day 1 Rituxan/CHOP today.


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## LLovett (Sep 28, 2010)

I don't see 5s either. Why does the doctor think these are 5s?

1st example, the exam is not comprehensive by either 95 or 97 guidelines and the MDM is Low at best because you have max of 2 dx points (that I see, the CA and history of the bleed), 2 data (1 for labs and 1 for CT order), risk is moderate from what I see but even if you want to argue high you are stuck because of the data/dx points. I say this is a 99214 unless time is documented somewhere else to support the 5.


2nd example, this one is lacking HPI so you are stuck at EPF history, exam is EPF exam by 97 or Det by 95, and MDM is straightforward because you only have 1 dx point, 1 data point, and moderate risk. This should be a 99213, unless there is time documented somewhere else to support higher.

Just my take on it,

Laura, CPC, CPMA, CEMC


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