# Can I bump this to a level 4 (establish)



## daniel (Jan 27, 2008)

Help me out there, looking at this and seeing a possible four, if you see the same thing. Help me out and clear it up for me. And if you see just a level three but a possible level 4, but it's just missing something let me know. 
Going to be doing an internal get together with my physicians. Trying to bring all the examples of level fours to light. 


Reason for Visit:
        ROT- LABS

 C/O Cough, chest, cold, X 2wks. Zero going awaY- FEVER X 1 month.

PFSH: NKA

January 00, 2777

RE: what you name

He is a 56- year old gentleman here for follow-up of his lab results. He had started on TriCor for hypertriglyceridemia. He had follow-up blood work done on January 11, 2008. This revealed a drop in his triglycerides from 307 to 133 and his cardiac risk ratio from 4.5 to 3.4. He did, however, have a slight bump in his AST from 28 to 38, about 10% above normal. He has since run out of the TriCor.

In the interim he came down with an upper respiratory infection, initially a cold that moved into his chest. He is coughing productively, having some shortness of breath in the middle of the night, awakenign anxiously, and a low-grade fever. He is concerned that it might be the lisinopril causing his cough. He also has been doing home blood pressure readings which he states average about 130/80 to 85. He is a little higher in th office today at 142/100. His pulse is also 90.

PHYSICAL EXAM:
      HEENT: withing normal limits. He does have some nasal congestion but    no erythema or purulent drainage. TMs are normal. His pharynx reveeals a little uvular edema, but no exudates.
      Neck:Supple
      Lungs: No rales or wheezes. A few rhonchi.


I think he has a bronchitits. Will treat him with Zithromax, Mucinex and Zyxel. This may also be related to his elevated LFT, however, it is more likely the TriCor. Given its minimal elevation, we are going to continue the prescription and repeat another lipid and metabolic panel in six weeks. Hopefully his respriatory infection will clear with the above approach as well. We will see him for follow-up thereafter. 


Thank You in advance for those who post there opinion.


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## donsqueen (Jan 27, 2008)

This is almost a 4th level, but without a referral or further workup to confirm bronchitis, I wouldn't code it higher than a level 3.


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## Jagadish (Jan 28, 2008)

I think it is Level 4. Detailed History and Detailed Exam (95 guidelines - 2 systems in detail - constitutional and HEENT)


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## mmelcam (Jan 28, 2008)

I agree, per 1995 guidelines it is a level 4. There is a detailed history and a detailed exam. Medical decision making could be as low at straight forward and it wouldn't change the code. You meet detailed for the first 2 components (history & examination) and that is all that you need for an established office visit level 4.


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## m.j.kummer (Jan 28, 2008)

The level must be driven off of the medical decision making.  Even if there is a detailed history and exam which I do not see the medical decision making is what drives the level.  If you can show me a detailed history or detailed exam the level would bump to 99214.  My reasoning is noted below:

HISTORY
HPI = 4 (extended)
ROS = 3 (extended)(constitutional, respiratory and possibility psych for awakening anxious)
PFSH = none (expanded problem focused) (we know he has a medical history, does he smoke? this would be pertinent)
All three count in determining the history level.  History is expanded problem focused.

EXAM
Constitutional = 0 blood pressure and pulse are documented, must have 3HEENT = 3  nose, tympanic membranes and pharynx are documented
Neck = maybe one point for the word supple
Lungs = 1 adventitious sounds are the only elements documented
Exam contains 4 or 5 elements making it a problem focused exam

Medical Decision Making
Diagnosis and Treatment Options = 3
We can assume it was a new problem to this examiner with no additional work up planned.  It isn't self limited or minor because the cough may be due to medication making it a bit more complex.
Risks = moderate
The patient will be managed with percription medications as of this visit
Data Review = 1
Labs were reviewed
Medical Decision making is moderate because we are allowed to toss out the lowest element.

Do you agree?


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## khaspert (Jan 28, 2008)

*99214*

If we are using the 1995 guidelines I would code as the following:

HPI= (4)extended
ROS= (3) detailed
PFSH= (1) detailed  (there is considerable discussion about this patients past tx for his high trigs

Exam= (4) exp problem focused
(1)Neck, (1)Respiratory, (1)eyes (WNL) and (1)EENT= (4)

Decision making 

Tx options (3)
Data reviewed (1)
Risk = moderate
all add up to Moderate complexity

Put them all together they spell 99214.  The physician should also have documented more clearly the elevated LFT's, elevated blood pressure and the hypertrig prolbems in his/her plan in order to support the level further.


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## mmelcam (Jan 29, 2008)

Correct me if I am wrong, but in 1995 guidelines for an established office visit you are only required 2 components out of the 3. If both History and Examination are detailed then it would not matter if the medical decision making was as low as straight forward because you would have already hit the 2 components with the history and examination.


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## daniel (Jan 30, 2008)

*Original Poster*

I agree partially with all of you out there. One question. Seems like you all (except) one, over looked. The fact that the Dr. made a decision on whether to continue his TriCor. Doesn't this count for a moderate decision making. Being he managed his prescriton. Give your opion.

Thank You All 
Daniel CPC


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## rthames052006 (Jan 31, 2008)

daniel said:


> I agree partially with all of you out there. One question. Seems like you all (except) one, over looked. The fact that the Dr. made a decision on whether to continue his TriCor. Doesn't this count for a moderate decision making. Being he managed his prescriton. Give your opion.
> 
> Thank You All
> Daniel CPC



Daniel...

I feel the same as you on this note, it seems some missed the Tricor part of this note...

Roxanne Thames, CPC


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