# Audit question



## abill_423 (Sep 23, 2008)

How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!


Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim.  At his last office visit he was having another episode of acute renal failure.  His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.  

CURRENT MEDICATIONS:  
1.	Altace 10 mg b.i.d. 
2.	Amiodarone 200 mg q.d. 
3.	Coumadin sliding scale. 
4.	Coreg CR 40 mg q.d. 
5.	Torsemide 20 mg q.o.d. 
6.	Repliva q 3 days. 
7.	Flomax .4 mg q.o.d. 

PHYSICAL EXAMINATION:
Alert and oriented x 3.  No complaints of chest pain or shortness of air. Weight:   178.  Blood pressure:  140/80. Pulse: 64. HEENT:  Negative. Lungs: Clear. Heart:  No murmur, rub or gallop. Abdomen:  Nontender.  Extremities:  No edema.  Skin:  No rash.  

LABORATORY DATA:
Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51. 

ASSESSMENT:
1.	Acute renal failure, revolved. Renal function back to baseline.  
2.	Vitamin D deficiency with mild hyperparathyroidism. 
3.	Good blood pressure and volume control. 
4.	ALLERGY TO SULFA.
5.	Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.  

PLAN:
1.	We put him on 800 IU of vitamin D q.d. 
2.	We didn't change any other medications. 
3.	Return in 6 months. 
4.	Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.


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## Belinda Frisch (Sep 23, 2008)

Absolutely, I'd bill it a 99214. Here's why...

On quick audit, I credit:
EPF history 
(1 cc reviewed, minimal HPI--more past history), 3 ROS (CV-chest pain, Resp-"shortness of air" taken from exam, but are ROS items, GU), Past history (meds, operations, hospitalizations)

Comprehensive Exam (95 DGs)

(8+ BA/OS: head, eyes, ENMT (HEENT), constitutional (vitals), CV, Resp, GI, skin, psych (alert, oriented X3)

MDM of moderate decision making
(3-4 established dx--per assessment--number of diags/treatment options, review of labs, and two or more stable, chronic illnesses per the table of risk)

2 out of three makes this a 99214

Agree?





abill_423 said:


> How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!
> 
> 
> Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim.  At his last office visit he was having another episode of acute renal failure.  His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.
> ...


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## ARCPC9491 (Sep 23, 2008)

abill_423 said:


> How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!
> 
> 
> Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim.  At his last office visit he was having another episode of acute renal failure.  His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.
> ...



I would use the exam and medical decision making:

1995, I get Comprehensive (8 organ systems) - constitutional, psych, cv, resp, gastro, musculo, skin, enmt

1997, I get Expanded Problem Focused: 1 bullet gen appear, 2 bullet psych, 3 bullet 3/7 vitals, 4 bullet ausc lungs, 5 bullet ausc heart, 6 bullet exam of abd, 7 bullet extrem for edema, 8 bullet skin exam

Medical Decision Making:
2+Est prob, stable
new prob, no work up (Vit D def)
total 4+ points

Order Labs 1 point

Risk: rx drug management (vit d) or 2 stable chronic illnesses

MDM - Moderate

Level: 99214 - i agree


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## dballard2004 (Sep 24, 2008)

I agree!  It is a 99214!


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## dmaec (Sep 24, 2008)

WOW ! well - I agree with the doc - I'd call it a level 2 - here's my reasoning -
I get a Problem Focused History (appears the patient is in for a follow up of his recent issue and hospital stay - basically a lot of "previous medical history" given there in the first paragraph and not a whole lot of HPI). ROS - I get "none" or 1-constitutional if I pull it from the exam, which really doesn't matter because - my HPI is still lowest at "problem focused". PFSH - I have Detailed "previous medical" ...as I stated, the first paragraph covers that.  SO - all in all - HISTORY COMPONENT is "PROBLEM FOCUSED HISTORY".
EXAM - I pull everything out of it rather than putting the constitutioanl in the ROS - and I get a COMPREHENSIVE EXAM.
MDM - I get STRAIGHT FORWARD  - Established problem to examiner, labs yes, and low to moderate complication risk - either way - the MDM = STRAIGHT FORWARD 
so - 
HISTORY = PF
EXAM = COMP
MDM =SF
2 of 3 elements met which brings it down to the 99212.  In my opinion, the doc knew this was a follow up and chose his level accordingly. Though the exam was "comprehensive", the rest of the visit was limited.
_{that's my opinion on the posted matter}_


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## aguelfi (Sep 24, 2008)

I agree w/ Donna.  I don't see a 4 either.  I get a 3 instead.  
Vit D is an over the counter Drug = low risk not moderate.


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## ARCPC9491 (Sep 24, 2008)

Here's my reasoning for MDM...

Problem Points:
Stage III Chronic Kidney Disease, Stable = 1 point
Nephrosclerosis, Stable = 1 point
_(you do get credit for more than 1 est stable prob, with a max of 2)_
Vit D Deficiency w/ mild hyperparathyroidism, New problem(s)
..and we can stop there, b/c we've maxed out our problem points, exceeding 4+

Labs, 1 data point

Stage III Chronic Kidney Disease, Nephrosclerosis (2 chronic conditions, stable) Moderate Risk

(Vitamin D _can _be rx. At a glance I thought under Plan, it said: No other changes made to _prescriptions_, but after re-reading, it said _medications _and given the dosage, it can be bought OTC. Bad judgement on my end to use in this case)


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## aguelfi (Sep 24, 2008)

but the renal failure is back to normal.  Documentation states that his last attack was acute and now longer applys, either way this pt has normal renal function.  Where's the dx in that, it's resolved.


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## ARCPC9491 (Sep 24, 2008)

abenson, 
I'm not using the 'acute renal failure' in my medical decision making. I understand that it's resolved - but resolved or not, a patient can still have chronic kidney disease _and _acute renal failure at the same time - the acuity and failure to his kidneys may no longer be a threat at this time - _but the CKD still exists. _


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## aguelfi (Sep 24, 2008)

i stand corrected


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