# Clinical Examples???



## btadlock1 (Mar 17, 2011)

This is probably going to sound like a stupid question, but is there another place to find clinical examples for outpatient E/M services, besides Appendix C? I need to find some that are a little more relevant to the charts I'm auditing...


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## btadlock1 (Mar 17, 2011)

*Level III or IV?*

25 year old established patient, 17 weeks pregnant, fever, productive cough, sinus drainage, congestion, sore throat, SOB, and bilateral earache.
Duration: 5 days
Course: Worsening 
Negative for influenza
Diagnosis: Acute Bronchitis, Acute suppurative otitis media NOS
MD performed nebulizer Tx in office (94640), and prescribed cefprozil 500mg
Also advised to get lots of fluids, rest, tylenol for fevers and discomfort. 

He documented a comprehensive history and exam, and moderate MDM by my count (he almost _always_ has either a detailed or comp H&P - his biggest trouble area is matching his work to the medical necessity of the presenting problem), and he scored this as a 99214 - was this visit severe enough to warrant a level IV exam? (Or even level V, for that matter?)

I've read the examples in the CPT about 100 times, now, and none of them are really similar enough to this to fit. Any thoughts?


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## cheermom68 (Mar 18, 2011)

*Level 4*

I think that if this was a new problem(first visit for this particular problem) it would meet the medical necessity for a level 4, in my opinion.  
LeeAnn


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## FTessaBartels (Mar 18, 2011)

*Medical Necessity*

I am not a doctor, so I do not second-guess the physician's documentation as far as whether it was medically necessary to do X vs Y.

If the documentation supports a level 4 visit, that's the code.

But to answer your question, Brandi ... you have a 17-week *pregnant *female with *worsening* symptoms, and ultimately diagnosed with bronchitis serious enough to require a nebulizer *treatment in the office*, plus Rx.  

I have seen plenty of visits for kids with otitis medea coded to a 99214.  

I certainly wouldn't argue with the doctor's decision to perform what s/he performed and documented. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## btadlock1 (Mar 18, 2011)

FTessaBartels said:


> I am not a doctor, so I do not second-guess the physician's documentation as far as whether it was medically necessary to do X vs Y.
> 
> If the documentation supports a level 4 visit, that's the code.
> 
> ...



In this situation, no I wasn't questioning his exam - but over 60% of his E/M's are billed out as 99214's, whether the medical necessity is there or not. Our MAC is VERY picky about level 4 and 5 codes - they say not to even _consider_ the higher levels unless the patient has a 50/50 chance of loss of life or bodily function without immediate treatment. Thanks for the input! I'll go with 99214 on this one, then.


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