# Level?



## Gemini18 (Mar 24, 2009)

HPI - 34 yo male sent to ER after an intentional drug overdose.  Pt reports he wanted to kill himself - "tired of living this life", took a handful of pills - Klonopin, Seroquel, Invega, stool softener and Tegretol.  Pt reports he took all those pills over the past few hrs and had attempts in the past.  Sister called EMS.  Presently he denies CP, SOB, N/V or abd pain.  

ROS - Head, Nose, Pharynx, CV, RESP, GI, Musculo, and Neuro

PMH - schizoaffective disorder, multiple suicide attempts.
SH/FH - Disabled, drug use, mother deceased, sister alive

PE - 11 systems examined.
Labs, EKGs - done

Pt admitted to ICU with IV saline.  Will consult psychiatrist for further evaluation

What would be the level for this?  I'm getting a level 3 due to the pt's chronic mental illness.


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## ARCPC9491 (Mar 24, 2009)

CC: Drug overdose
HPI: 
Duration-past few hours 
A/s-attempts in past
ROS- 6 (head doesn't count, it's considered a body area)
PFSH- 3/3
History: *Expanded Problem Focused*

Exam: you state 11 systems examined. This would be *comprehensive *based on 95 DG's.

MDM:
New prob (I'm assuming new problem) w/ work up.. 4 points 
Labs 1 point
EKG 1 point
Risk: IV fluids and/or chronic illness w/ exacerbation...moderate risk
MDM: *Moderate*

The documentation states patient was admitted. By your physician? Probably so. The documentation doesn't justify even the lowest level admission, 99221.(This requires comprehensive/detailed history, comprehensive exam, medical decision making of low/straightforward) The only difference between the higher two levels is the MDM (moderate, high, respectively..) and of course the time is different. 

I, personally, would educate your physician. (Primarily in documenting a complete history..hit atleast 4 HPI elements, complete 10 point ROS..) Maybe even review a few more of his/her admissions, show them what the requirements are and what their documentation must consist of. 

The note you have posted is not billable unless you take the route of billing an unlisted E/M code, 99499, sending in the documentation, and letting the payer decide how much the reimbursement is.


Good luck!


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## LLovett (Mar 24, 2009)

_ALL levels of admission require both comprehensive history and exam. The only difference between the 3 levels is the MDM (low, moderate, high, respectively..) and of course the time is different. _

99221 is Detailed or Comprehensive history and exam, they don't have to be comprehensive.

I think this is a detailed HPI so it would put the history level up to detailed.

HPI - 34 yo male sent to ER after an intentional drug overdose(chief complaint). Pt reports he wanted to kill himself (context)- "tired of living this life" (severity), took a handful of pills - Klonopin, Seroquel, Invega, stool softener and Tegretol (modifying factor). Pt reports he took all those pills over the past few hrs (timing) and had attempts in the past (possibly duration). Sister called EMS. Presently he denies CP, SOB, N/V or abd pain. 

Just my take on it, whether or not you agree with the HPI elements at least be aware you can have an admit with a detailed history and exam.

Laura, CPC


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## ARCPC9491 (Mar 24, 2009)

Thanks for catching that! I always do that with 99221 & I don't know why! I corrected my post...


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## ARCPC9491 (Mar 24, 2009)

HPI - 34 yo male sent to ER after an intentional drug overdose(chief complaint). Pt reports he wanted to kill himself (context)*To me, context is more of, where and what was the patient doing?*- "tired of living this life" (severity)*this is tough because severity is like on a pain scale 1-10, but on the flip side, I guess you could argue his life was so bad it got severe enough he wanted to take his life.* took a handful of pills - Klonopin, Seroquel, Invega, stool softener and Tegretol (modifying factor)*The documentation doesn't say what these drugs did to him, he obviously didn't die, he has no positive ROS listed, so really what effect did it have? If he stated patient lethargic, vitals low, heart stopped, or what have you... I think I would count it then as modifying factor * Pt reports he took all those pills over the past few hrs (timing)*I would rather this be duration, timing is more specific like intermittent, constant, etc.* and had attempts in the past (possibly duration)*I would use this as associated signs/symptoms demonstrating the destructiveness this disease has on him.*. Sister called EMS. Presently he denies CP, SOB, N/V or abd pain. 

Just my thoughts....


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## Gemini18 (Mar 24, 2009)

*Thanks*

It was coded as a 99222.  I had a 99221.

Thanks everyone!


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## FTessaBartels (Mar 25, 2009)

*Just the HPI*

I just love E/M coding because it's so open to interpretation (slightly sarcastic tone).

You don't say if you have a chief complaint stated independently of the HPI. So I'm counting "drug overdose" as the CC.

For the HPI, I'd consider:
Quality: intentional, tired of living this life
Context: took a handful of pills
Severity: the listing of all the pills
Duration: over past few hours
Modifying factors: attempts in past; sister called EMS 
Assoc signs: denies CP, SOB, N/V or abd pain

Adding up the ROS and PMFSH,  I'd get a *detailed *history

So you have a 99221.

Good idea to educate your physician that without 10+ ROS and a 3/3 PMFSH  you can never get above a 99221. 

Just my thoughts ...

F Tessa Bartels, CPC, CEMC


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