# Daily Dilemma 99213 or 99214?



## amexnikki23 (Aug 12, 2015)

Chief Complaint(s):   F/U on med

  HPI:   Established problem follow-up on Anxiety, 26 year old female presents with c/o ANXIETY F/U  worsening. She has h/o anxiety but it is getting worse recently.  
         Denies : SLEEP DISTURBANCE. ENERGY CHANGE. WEIGHT CHANGE. APPETITE CHANGE. CONCENTRATION. ANHEDONIA. SUICIDAL IDEATIONS. RACING THOUGHTS. HALLUCINATIONS. 
         STRESSORS  worsening, at work.  SUPPORTS  significant, support from spouse.  PANIC ATTACKS  more frequent panic attacks, more intense.  MOOD  irritable, anxious, worried about everything, overwhelmed.  
         She has been using Clonazepam as needed. 

 Taking Clonazepam 0.5 mg tablet 1 tab(s) once a day prn, Notes: prn 

           ROS:
     CONSTITUTIONAL
        no Unusual weight change.  no Fever.  no Chills.  no Fatigue.  
     CARDIOVASCULAR
        no Chest Pain.  no Shortness of Breath.  no Palpitations.  
     GASTROINTESTINAL
        no Nausea/Vomiting.  no Constipation/Diarrhea.  no Abdominal Pain.  
     NEUROLOGIC
        no Headache.  no Weakness.  no Tingling/Numbness.  no Visual Changes.  
     PSYCHIATRIC
        Panic Attacks yes.  Mood Swings yes.  no Depression.  Anxiety yes.  Stressors yes.  no Suicidal Thoughts.  no Paranoia.  no Hallucinations.  

EXAM: 
        General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.  
Skin: normal, no rash or skin lesions on exposed skin, moist, warm.  
Heart: Regular rate and rhythm, no murmurs.  
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.  
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.  
Neurologic Exam: alert and oriented x 3, CN's grossly intact, gait normal.  
     Psychology
        Grooming : adequate.  
Eye contact : normal.  Mood : anxious.  Affect: anxious.  
Speech: Normal.  Association: Normal.  Insight: Good.  
Judgement: Fair.  Hallucinations: None.  Thought Process: appropriate.  
Memory: Intact.  Abnormal Thoughts Perceptions None.  

Assessment: 
  Assessment:
  Generalized anxiety disorder - 300.02 (Primary) 

Plan: 
  Treatment: 
    Generalized anxiety disorder 
        Start Escitalopram Oxalate tablet, 10 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 1 
         Notes: Will start SSRI's. Side affects discussed in detail. Warned about succidal ideation in the first week of start. Will follow up periodically. Pt educated with multium medication printout.


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## a.renee86 (Aug 12, 2015)

Looks like 99213 to me. Provider has a moderate MDM considering the medication management, however, exam and hx look to be Expanded problem focused. So established pt goes with 2/3. 

I hope this helps,
Amber


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## thomas7331 (Aug 12, 2015)

You code this 99214 as it qualifies by having a detailed history, detailed exam and low complexity MDM.  I've seen some auditors challenge a 99214 in a case like this because it only addresses one problem in f/u with a prescription, but it does meet the CPT definitions for that level.  Anyone else have any thoughts?


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## mitchellde (Aug 12, 2015)

CMS states that the overarching criterion for any given level of service is medical necessity.  So while it can be assessed to this degree the question is given the medical necessity (follow up for medication) SHOULD it be this level.  In my opinion no you do not need this degree of exam and history for a follow up for a med.  it should be 99213 as the medical necessity does not warrant any higher than that.


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## amexnikki23 (Aug 13, 2015)

What do you all think about the "exacerbation" of the established problem, worsening? In this case, the "mood".  

I was reading an EM auditing article yesterday here on AAPC and it had some conflicting opinion on the MDM points calculator. It used "established problem, worsening" and "new exacerbation of an established problem: in two different contexts. As if the latter would be considered a "new problem" to which I initially would disagree, but now, not so sure. Another coder here suggested the provider add "mood disorder" to this established diagnosis, and code a 99214. 

Thoughts?


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## thomas7331 (Aug 14, 2015)

I agree with Debra's line of thinking above, but with some hesitation.  When I sat for the CEMC exam recently, the AAPC guidelines in the test and practice exam advised that coding should be done from the CPT definition and that only a provider's peer should evaluate medical necessity.  This is something I struggle with on a daily basis as I find it difficult to give good guidelines to coders on how to evaluate medical necessity.  When coders drop a level of a visit simply because they exercise their own judgment that the level is not warranted, our providers tend to get very upset.  I find that the providers are usually quite able to articulate why they felt it necessary to perform each element that they document.  But it doesn't work to ignore medical necessity either, as that inflates the levels any many cases.  Has anyone else had this issue?


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## amexnikki23 (Aug 17, 2015)

Yes, I definitely have that problem. The providers are not happy when I drop a level. But I think I do it for good reason, and that is lack of adequate documentation. We as coders cannot read between the lines and think like the provider was thinking at the time he/she chose the level of code that they did. When all I see is what's in front of me, I use the points scale, and to me, unless I see documentation demonstrating a higher level of MDM, to me, it speaks for itself. At my practice, we're told the MDM always drives the visit. So that only leaves me with either the Hx or the Exam. I'd much rather go by CPC guidelines to be honest with you. But I guess that's where the Medical Necessity comes into play, and then the game begins again. Ugghh..


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## ljhaley@gmail.com (Aug 18, 2015)

*same struggle here too!*

Glad to know I'm not alone! I'm in Peds, our practice used to be a "two out of three" determines level. Then they realized MDM/Med Nec. should drive the coding. I truly need help with this problem: I have a NP that does a Det hx and Det exam on EVERY patient because she feels that's "good medicine." She codes 99214's a LOT.  I review and re-code many of her's to 99213's based on MDM/MN. She fights me every time, even though I've gone over how MDM/MN works and had provider training with an outside agency. She is very efficient, & see's a ton of patient's, thus "Time spent" is not a deciding factor. 

How can I get her to understand MN/MDM and code appropriately? I've tried E&M university and CMS publications, Does anyone out there have a suggestion/similar issue in their practice? Thank you!


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## amexnikki23 (Aug 26, 2015)

I'm signing up for the MN vs. MDM workshop in Sept. I think that will cover a lot of this, as it appears many are experiencing the same dilemma. Once I take that webinar, I will revisit this post and see what everyone is saying out there...


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## Quaker (Sep 3, 2015)

*In the same boat*

I struggle with the same issues as referenced above on a DAILY basis!!  I also have signed up for the E&M MN vs MDM class.  Hopefully this class will be able to end the confusion but I may have high hopes!!


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## stacyterramiggi@hotmail.com (Sep 10, 2015)

*99213 Vs 99214*

We recently had this dilemma in our office and it cost someone their job because the coder did not feel the visit warranted the use of a 99214 and therefore down coded to a 99213. Our providers had a meeting and explained the choice on the level of service on a 99214 may not seem to us ( coders ), that it warrants that level of service, however our system EMD's picks the code and then the physician's can choice to agree or disagree. The Dr.'s ( coder's ) has to review the chronic conditions listed in the H&P and the ROS. Example:the medications the patient are prescribed already and any new med's and any possible side effects that this may have on other conditions as well as the one the patient is receiving the new medication for. Sometimes it appears that a 99214 is over coding but actually is not. Our Physician's asked that if we think it is an over coding or under coding to please speak with them prior to changing the code or (level of service ) this way both Dr. and Coder are educated as to the why we feel this is so. We are very lucky that our Dr.'s are very approachable, this is always a plus. So in a nut shell for our practice it is now a group effort.


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