# Retail Health Clinic and MDM selection: advice needed



## krburke (Mar 9, 2010)

I am working on a small audit of a retail health clinic.  The trend I see is that the documentation supports a 99214, but the MDM is still a bit questionable to me, and the providers seem nervous about filing higher level visits.  In most cases, they are prescribing at least one medication, so they are scoring at the Moderate level on the table of risk for management options, but if the nature of the presenting problem needs to drive the medical necessity of the visit, they would typically only score Low on MDM.  In the example I have described below, would a 99214 be supported by this documentation?  Even though the presenting problem scores Low on MDM, does the presence of 2 chronic illnesses (HTN and GERD) help support Moderate MDM in addition to the prescription management?  Would they need to specifically state that the HTN and GERD are stable in order to count towards Moderate MDM?  Thank you in advance for your input on this!

35 y/o female pt came in complaining of sore throat (feels scratchy, better now), cough x 1 week (thick, yellow, cloudy), headache (left, frontal)
Denies fever, postnasal drip, facial pain, SOB

ROS: GI no nausea, no vomiting, no diarrhea
Medical history: HTN and GERD
Medications: Nexium 40, 1 daily; methyldopa 500, 2 daily
NKDA

Vitals: Temp 97.8, RR: 16, HR: 87, BP: 132/82
Pulse Ox: 98%
General Appearance: pleasant, NAD
Ears: auditory canals normal bilaterally, tympanic membranes normal bilaterally
Sinuses: non tender bilaterally
Oral cavity: no erythema or exudates seen on pharynx
Neck: no cervical lymphadenopathy
Heart: RRR, normal S1 S2, no murmurs
RESP: scattered wheezes throughout, no rales, no ronchi, resp even/unlabored
Skin: pink, warm, dry, no rash

Assessment:
Acute bronchitis NOS (466.0)
Cough (786.2)

Plan:
Acute bronchitis NOS
Start Biaxin tablet, 500mg, orally, 20, 1 tab(s), Q12H, 10 day(s), Refills 0;
Start Medrol Dose Pak, Tapering Dose, orally, 1 PAK, as directed, Refills 0;
Start albuterol aerosol, CFC free 90 mcg/inh, inhaled, 1 MDI, 2 puffs, QID PRN, Refills 0;
Discussed correct use and possible side effects of medications.  Instructed on use of OTC Tylenol/ibuprofen PRN fever/body aches.  Increase fluids and rest. If increased fever, pain/discomfort, difficulty breathing, or SOB occur seek immediate medical attention.  Verbalized understanding.

Follow-up: 3-5 days if symptoms persist, sooner with worsening


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## FTessaBartels (Mar 9, 2010)

*Acute bronchitis*

In my opinion, acute bronchitis by itself would qualify for moderate risk. 

Acute bronchitis is not the same as a minor sore throat or cough that will go away on it's own. The provider even wants the patient to return in 3-5 days (or sooner if problem gets worse).

Hope that was helpful.

F Tessa Bartels, CPC, CEMC


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## melloyello31 (Mar 9, 2010)

In my opinion the exam can be either expanded or detailed depending on your auditing tool and with acute bronchitis being moderate risk, I can see why you would code this visit a 99214.


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## krburke (Mar 9, 2010)

FTessaBartels or melloyello31,
I'm still fairly new to auditing.  Can you help me understand how acute bronchitis gets me to moderate?  I didn't think I was seeing any _systemic symptoms_ in the note.  What am I missing?

Thanks!

Kathy


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## melloyello31 (Mar 9, 2010)

HTN is a chronic condition alone so that's a moderate risk level and also if acute bronchitis is new problem then that's all the proof you will need to support the 99214.


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## melloyello31 (Mar 10, 2010)

You actually may not be missing anything. Just reread what the doctor says about the bronchitis. Look to see what he states is the pt's symptoms. And if that's still not helping you come to the conclussion that the risk is moderate, u can also use HTN cause that's a chronic illness and I'm sure the pt has Rx for it.


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