# 99213 versus 99214



## LeaHarris (Sep 20, 2018)

I always feel stressed when we have a new provider come on board with our facility and we have differences on E/Ms.  In this case the provider coded this visit as 99214.  I down coded it to a 99213 based on the following (follow up on one problem worsening or not responding to treatment, HPI, and time spent with patient).  I do thing the MDM is Moderate but I am not sure that trumps everything else?  I would appreciate your opinions!


75 year old female who is 1.5 weeks post-op from aortic valve replacement (TAVR), with history of peripheral neuropathy, multiple spinal surgeries, Addison's disease, atrial fibrillation s/p AICD/pacemaker on warfarin, CAD here for left leg pain and increased swelling. 
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Leg swelling. 
- INR 1.3
-no lightheadedness/dizziness
- has had palpitations the last few days; had them most recently this am. 
-feels like she is getting adequate air; no shortness of breath
-no chest pain
-left leg swelling from knee down worse than usual 
-new pain in her calf that is different from her neuropathic pain. 
-neuropathy in both feet, unable to tell whether there is pain or tingling
- no history of DVT or PE that she can recall.
- she does not believe that she was on heparin or lovenox in hospital.  She is very worried about an allergic reaction if she were to start a new medication today. 


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Dr. Siwek's note says: "Coumadin was started for possible valve leaflet thrombosis. Did not improve gradient - hence TAVR. Probably not unreasonable to continue initially post TAVR but indication/duration a little unclear."
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Review of Systems 
Constitutional: Negative for chills and fever. 
Respiratory: Negative for cough, shortness of breath and wheezing.  
Cardiovascular: Positive for palpitations and leg swelling (left leg). Negative for chest pain, orthopnea and PND. 
Gastrointestinal: Positive for nausea. Negative for constipation, diarrhea and vomiting. 
Genitourinary: Negative for dysuria and urgency. 
Skin: Negative for rash. 
Neurological: Negative for dizziness and headaches. 
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Patient Active Problem List
Diagnosis
•	Chronic adrenal insufficiency (HCC-CMS)
•	GERD (gastroesophageal reflux disease)
•	Vaginal prolapse
•	Psoriasis
•	Atrial fibrillation (HCC-CMS)
•	Pacemaker
•	Breast cancer screening
•	Pernicious anemia
•	Mitral valve insufficiency and aortic valve insufficiency
•	Mixed hyperlipidemia
•	Peripheral vascular disease, unspecified (HCC-CMS)
•	Coronary artery disease with angina pectoris with documented spasm (HCC-CMS)
•	Colon cancer screening
•	Essential hypertension
•	Controlled substance agreement signed, pending scanned documents
•	Fusion of spine of thoracolumbar, multilevel fixation screws, hx revision fo broken hardware
•	Other osteoporosis without current pathological fracture
•	Chronic obstructive pulmonary disease (HCC)
•	Proctitis
•	Gout
•	Allergic rhinitis
•	Chronic pain of multiple sites
•	Hypertrophic cardiomyopathy (HCC-CMS)
•	Chronic pain of right knee
•	Opioid dependence on agonist therapy (HCC-CMS)
•	Pulmonary hypertension (HCC-CMS)
•	Ulcer of great toe (HCC-CMS)
•	Physician orders for life-sustaining treatment (POLST) form indicates patient wish for full code resuscitation status
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Past*Medical*History
Past Medical History:
Diagnosis	Date
•	Addison disease (HCC-CMS)	*
•	Asthma	*
•	Cataract	*
•	DJD (degenerative joint disease)	*
•	Fibromyalgia	*
•	GERD (gastroesophageal reflux disease)	*
•	HTN (hypertension)	*
•	Hypercholesterolemia	*
•	Mammary dysplasia	*
•	Pap smear	12-29-05
*	normal
•	Psoriasis	*
•	PUD (peptic ulcer disease)	*
•	PVD (peripheral vascular disease) (HCC-CMS)	*
•	Rhinitis, allergic	*
•	Tobacco use disorder	*
•	Vaginal prolapse	*
•	Valvular heart disease	8/29/2015
*	11/2012 s/p tissue mitral and aortic valve replacement b Dr Siwek. Severe MR with hypertrophic cardiomyopathy, mild aortic stenosis. 

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Past*Surgical*History
Past Surgical History:
Procedure	Laterality	Date
•	APPENDECTOMY;	*	*
•	ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING, ARTICULAR CARTILAGE (CHONDROPLASTY)	*	*
*	benign bone tumer removed
•	COLONOSCOPY	*	10-29-12
*	Dr.Rose
•	COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DX, W/WO SPECIMENS/COLON DECOMP (SEP PROC)	*	7/28/16
*	Colonoscopy
•	CORONARY ART/GRFT ANGIO S&I	*	8/4/15
*	Coronary cath/angio
•	DOPPLER ECHOCARDIOGRAPHY; COMPLETE	*	7/2016
*	LVEF low normal, 50-55%.  Pacer/defibrillator present, bioprosthetic MV present and appears to be functioning normally.  Trace MR, mild TR.  PA pressure 47mmHg.  Bioprosthetic aortic valve appears to be functioning normally.
•	EMBOLECTOMY/THROMBECTOMY; FEMOROPOPLITEAL/AORTOILIAC ARTERY, LEG INCISION	*	6/30/15
*	Left common & deep femoral artery thrombectomy, left iliofemoral embolectomy, patch angioplasty of left common & deep femoral artery placment of left external iliac artery, Left 6/30/15 
•	EXTREMITY STUDY	*	8/4/15
*	Left LE US negative for DVT
•	FEM/POPL REVAS W/ATHER	*	*
•	HEMIARTHROPLASTY, HIP, PARTIAL	*	*
*	L total hip followed by reattachment of muscle following surgery
•	LAMINECTOMY, W/O FACETECTOMY/FORAMINOTOMY/DISKECTOMY, 1/2 SEGMENTS; LUMBAR	*	*
*	Laminectomy, Lumbar  13 back surgeries
•	NEUROPLASTY &/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL	*	*
*	bilateral carpal tunnel
•	OOPHORECTOMY, PARTIAL/TOTAL, UNILAT/BILAT	*	*
*	bilateral
•	REPAIR ARTERIAL BLOCKAGE	*	11/11/15
*	SUCCESSFUL PTA OF L COMMON FEMORAL ARTERY WITH DRUG COATED BALLOON  
•	UNLISTED PROC, FOOT/TOES	*	*
*	toe surgery by Dr. Clarke after shovel injured her toe.
•	UNLISTED PROC, LEG/ANKLE	*	*
*	"ankle surgery"
•	UNLISTED PROC, SPINE	*	*
*	thoracolumbar fixation hardware
•	VAGINAL HYSTERECTOMY, UTERUS >250 GMS;	*	*

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Social*History
Social History
*

Social History
•	Marital status:	Single
*	*	Spouse name:	N/A
•	Number of children:	5
•	Years of education:	14
*

Occupational History
•	Not on file.
*

Social History Main Topics
•	Smoking status:	Former Smoker
*	*	Quit date:	12/11/2008
•	Smokeless tobacco:	Never Used
•	Alcohol use	No
•	Drug use:	No
•	Sexual activity:	Not on file
*

Other Topics	Concern
•	Not on file
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Social History Narrative
*	Lives alone, her daughter lives a block from her

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Current Outpatient Prescriptions
Medication	Sig	Dispense	Refill
•	metoclopramide HCl (REGLAN) 10 mg tablet	Take 1 Tab by mouth 4 (four) times daily before meals and nightly	120 Tab	3
•	polymyxin B sulf-trimethoprim (POLYTRIM) 10,000 unit- 1 mg/mL ophthalmic solution	Place 1 Drop into the right eye 4 (four) times daily	10 mL	0
•	promethazine (PHENERGAN) 25 mg tablet	TAKE 1 TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR NAUSEA.	30 Tab	0
•	promethazine (PHENERGAN) 25 mg tablet	TAKE 1 TABLET BY MOUTH EVERY 8 (EIGHT) HOURS AS NEEDED FOR NAUSEA	30 Tab	5
•	buprenorphine-naloxone (SUBOXONE) 8-2 mg SL tablet	DISSOLVE 1/2 TABLET UNDER THE TONGUE 3 TIMES A DAY.	42 Tab	0
•	predniSONE (DELTASONE) 5 mg tablet	Take 2 Tabs by mouth once daily	90 Tab	3
•	ondansetron HCl (ZOFRAN) 4 mg tablet	TAKE 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED FOR NAUSEA.	60 Tab	3
•	allopurinol (ZYLOPRIM) 300 mg tablet	Take 1 Tab by mouth once daily	30 Tab	5
•	gabapentin (NEURONTIN) 600 mg tablet	Take 1 Tab by mouth 2 (two) times daily	180 Tab	6
•	ergocalciferol, vitamin D2, (VITAMIN D2) 50,000 unit capsule	Take 1 Cap by mouth once a week	12 Cap	3
•	PNV,calcium 72-iron-folic acid 27 mg iron- 1 mg tab	Take 1 Tab by mouth once daily	*	*
•	fluticasone (FLONASE) 50 mcg/actuation nasal spray	Place 2 Sprays into the nostril(s) once daily	16 g	11
•	carvedilol (COREG) 6.25 mg tablet	Take 1 Tab by mouth 2 (two) times daily with a meal	*	*
•	alirocumab 75 mg/mL pnij	Inject 75 mg into the skin every 14 (fourteen) days.	*	*
•	cyclobenzaprine (FLEXERIL) 10 mg tablet	TAKE ONE TABLET BY MOUTH THREE TIMES DAILY AS NEEDED FOR MUSCLE SPASMS	30 Tab	5
•	meclizine (BONINE) 25 mg tablet	Take 25 mg by mouth 2 (two) times daily as needed.	*	*
•	ENTERIC COATED ASPIRIN 81 MG TAB, DELAYED RELEASE	1T PO QD	30 Tab	11
*
No current facility-administered medications for this visit. 

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Objective 

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Vitals
Vitals:
*	09/17/18 1000
BP:	134/65
Pulse:	79
Resp:	16
Temp:	97.8 °F (36.6 °C)
TempSrc:	Oral
SpO2:	95%
Weight:	139 lb (63 kg)
Height:	5' 1" (1.549 m)


Last 3 Vitals 
 	Office Visit from 9/17/2018 in Winding Waters Medical Clinic	Office Visit from 9/13/2018 in WW JOSEPH MEDICAL CLINIC	Office Visit from 8/16/2018 in WW JOSEPH MEDICAL CLINIC
Temp	 97.8 °F (36.6 °C)	 97.8 °F (36.6 °C)	 97.5 °F (36.4 °C)
Pulse	 79	 85	 85
BP	 134/65	 106/56	 115/73
Resp	 16	 16	 20
Weight	 139 lb (63 kg)	 141 lb (64 kg)	 139 lb (63 kg)
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Estimated body mass index is 26.26 kg/m² as calculated from the following:
  Height as of this encounter: 5' 1" (1.549 m).
  Weight as of this encounter: 139 lb (63 kg). 
Facility age limit for growth percentiles is 20 years. 
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Physical Exam 
Constitutional: She is oriented to person, place, and time. No distress. 
Pale elderly female 
HENT: 
Head: Normocephalic and atraumatic. 
Right Ear: External ear normal. 
Left Ear: External ear normal. 
Nose: Nose normal. 
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. 
Neck: Normal range of motion. Neck supple. No thyromegaly present. 
Cardiovascular: Normal rate and regular rhythm.  
No murmur heard.
2+ femoral pulses bilaterally.  Unable to palpate DP or tibialis posterior pulses 
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. 
Abdominal: Bowel sounds are normal. She exhibits no distension and no mass. There is no tenderness. 
Musculoskeletal: She exhibits edema. 
1+ pitting pedal edema bilaterally  
Lymphadenopathy: 
  She has no cervical adenopathy. 
Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit. 
Skin: Skin is warm and dry. She is not diaphoretic. No pallor. 
Psychiatric: She has a normal mood and affect. Her behavior is normal. 
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Assessment and Plan:  75 year old female who is 1.5 weeks post-op from aortic valve replacement (TAVR), with history of multiple spinal surgeries, Addison's disease, atrial fibrillation s/p AICD/pacemaker on warfarin, CAD here for left leg pain and increased swelling.  Given recent surgery and subtherapeutic INR, there is concern for DVT/PE.  However, patient's leg swelling is relatively unimpressive with no erythema, warmth, collateral veins or significant enlargement compared to other side.  I reviewed discharge summary and records from her recent hospitalization.  Per her thoracic surgeon, unclear benefit of warfarin in this situation, and duration of therapy also unclear.  No shortness of breath now and VS are within normal limits, making pulmonary embolism less likely, but she has had palpitations last 2 days.  Other etiologies of palpitations could be cardiac arrhythmia such as rapid atrial fibrillation, dehydration, anxiety.  None of these are apparent today.  
- LLE duplex now. 
- shared decision making around CTPA - patient declines at this time and I think this is reasonable - see above.    
- will rx lovenox if US shows DVT.
- strict return precautions given - see instructions. 
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R60.0 Edema of left lower extremity  (primary encounter diagnosis)
Plan : • US STUDY FOLLOW-UP (SPECIFY) (Future)
          • US STUDY FOLLOW-UP (SPECIFY)
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I48.91 Atrial fibrillation, unspecified type (HCC-CMS)
Plan : • INR COAGUCHEK (POCT)
INR 1.3 today.  Plan to increase warfarin dosing to 10 mg on Monday and Friday and 5 mg the rest of the week. Recheck Friday 9/21/2018
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M79.605 Left leg pain
Likely explained by peripheral neuropathy. Continue gabapentin.  Will monitor. 
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Total of 20 minutes was spent with the patient.  Greater than 50% of time was spent in FTF counseling and coordination of care for the above diagnoses.  
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## Pathos (Sep 20, 2018)

Perhaps the physician thought he/she could get credit for the symptom code (R60.0)?

However, since the edema is a symptom of Afib, we generally do not count that towards the MDM. Afib looks like it is worsening as the provider is changing the prescription to a higher dosage. If the Afib is an *established* problem to the provider, then I agree with *99213* (_Exam is at least Detailed_). If the Afib is a *new* problem, then *99214* is correct and the provider coded right.

In general, Established Patient Visits require two out of the three E/M components (History, Exam and MDM). Some argue that MDM should always be part of the two, some suggest that it doesn't really matter. I personally think MDM should be one of the two (for reasons I can expand on at a later time).


Hope this is helpful!


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## liny (Sep 21, 2018)

*99213 vs 99214*

When Provider states the time spent with the pt. and  the verbiage documented here then that trumps all so 20 min  new pt is 99202/  20 min Established is 99213


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