# I get a 99214 do you.



## daniel (May 20, 2008)

This is an establish visit.
Do you get a level four out of this?



She is a 48-year old female here today for follow-up after a brief hospitalization back on April 12, 2008, at Inland Valley Hospital for menorrhagia. She ended up being admitted for two days, given four units of blood and was started on birth control pills and iron replacement.

She has a known history of a large uterine fibroid in the past. She has had some menorrhagia previously but has never had a significant drop in her hemoglobin. Her last measurement in January of 2007 was 11.3.

She is also concerned because her blood pressure is high today: it is 162/104, with a pulse of 90, and she is feeling a little short of breath. She awakened in the middle of the night with a nightmare.

Repeat blood pressure is 150/104.

The patient needs a referral for GYN consultation regarding either having an endometrial ablation versus a hysterectomy. I think given the size of her fibroid she is not likely a candidate for utierine artery embolization, however, that would be something to discuss with gynecologist.

Physical Exam: On exam today her lungs are clear. Her heart reveals a regular rhythm, without murmurs or gallops. She has no calf tenderness or ankle edema.

She was given business cards for Dr. Hughes and Henderson both of Medical Clinic for Women and also for Dr. Dietrich. She will call them to set up an appointment at her convenience. In the meantime recommend she obtain twice daily home blood pressure readings and update lab work, including a CBC. Will obtain her records from her hospitatlization[/B]. Will see her back for a recheck in a week.


Thank You in advance for your opion
Daniel
CPC


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## Jagadish (May 20, 2008)

MDM is moderate but I cant see either History or PE as detailed. For me, its 99213.


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## Susan (May 20, 2008)

If you use the 95 guidelines you could go with a 99214. Counting 3 systems, with the "detail" going to the cardiovascular system.


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## Lisa Bledsoe (May 21, 2008)

I see this as a 99213 based on an expanded problem focused history (I see a brief HPI) and exam...and I come up with a low complexity MDM becuase it is appears to be an established (worsening) problem to the provider (I would not think this is stable) - so 2 Dx/Treatment option points, one data point for CBC, and moderate risk = low complexity.  Any other opinions?

Lisa Curtis, CPC-I, E/M


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## Jagadish (May 21, 2008)

according to 1995 guidelines, you need 2-7 systems in detail. when was this changed? I need atleast 2 systems examined and documented in detail. for me, exam is EPF.


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## daniel (May 22, 2008)

Hey E/M coders, I'm the one who originally posted this thread. New to this E/M game. But I get an

PE= Detailed -- an extended examination of the affected body area(s) and other symptomatic
or related organ system(s).

MDM= Can go either way, 3 points for a new problem + 1 point for the referal for a consult = 4 points. 

Just because the patient is following up from the hospitlal, doesnt' mean it's not a new problem to the treating physician. 

Now to look it at how most of you are looking at it, 

MDM= 2 points for a establish problem woresening, 1 point for a self limited problem for the high blood pressure. Or you can count this as a new problem. Which would defintly give this  higher points. But let's just add these two as 3 points. And then you you get Moderate decsion making for the referral to the GYN consult. 

Which makes this case two out three, for the 99214.





P.S -REGARDING THE EXAM, DON'T YOU JUST NEED TO HIT AT LEAST ONE ORGAN OR BODY AREA OR ORGAN SYSTEM IN DETAIL. BECAUSE IF THERE'S NO OTHER symptomatic or related organ system(s) TO DOCUMENT. WHY WOULD YOU NEED IT. (1995 GUIDELINES)


Educate me if I'm way off, always open for the challenge.


Respectfully
Daniel
CPC


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## Jagadish (May 22, 2008)

I dont see a detailed history documented here. It would be great if it can be explained how one gets an detailed history out of this note?


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## Lisa Bledsoe (May 22, 2008)

I'm with Jagadish.  I don't see a detailed history and I don't see a detailed exam.  Even if it is a new problem to the provider with additional work-up and moderate risk, it's still moderate MDM.  Also, unless I'm missing something, when did we start giving points for referring to another provider?

I still see 99213. 

I'm up for debate on this as well...
Lisa


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## daniel (May 22, 2008)

I'm glad they made this website. Helps one like myself learn with each day. As I've read through all these response, I conceed. And going with 99213. You all cleared this up for me. 


Respectfully
Daniel
CPC

P.S- Just wanted to see witch way the E/M coding wind was blowing on this one.


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