# is this 99215



## perkins05 (Feb 7, 2012)

Does this note code to 99215? All responses are appreciated..

Earache *

Associated Diagnoses:   HTN (Hypertension), Benign; Ear Problems; Rhinitis, allergic; Obesity; Vertigo 


Chief Complaint 
  left ear clogged up leading to dizziness    

History of Present Illness 
          The patient presents with 35 y/o male here for  "clogging" left ear with dizziness and tinnitus.  States h/o vertigo.  Denies ear pain.

Also elevated bp.  Had recent labs at job in November with glucose, cholesterol which he states were normal.  Had elevated bp at work and on 2 occasions here. .  Exacerbating factors consist of none.  Relieving factors consist of none.  Associated symptoms consist of none.   

Review of Systems 
Constitutional:  No fatigue.  
Eye:  No recent visual problem, No blurring, No double vision, No visual disturbances.  
Respiratory:  No shortness of breath.  
Cardiovascular:  No chest pain, No palpitations, No peripheral edema, No syncope.  
Gastrointestinal:  No nausea, No vomiting, No abdominal pain.  
Genitourinary:  No dysuria.  
Integumentary:  No other significant skin complaints.  
Neurologic:  No headache.  
ROS reviewed as documented in chart 

Health Status 

Allergies: . 
Allergic Reactions (Selected)
No known allergies 

Medications:  (Selected). 
Prescriptions
Ordered
Augmentin 875 mg oral tablet: 1 tab(s), PO, q12hr, # 20 tab(s), 0 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752
Medrol Dosepak 4 mg oral tablet: 1 packet(s), PO, Once, Instructions: as directed on package labeling, # 21 tab(s), 0 Refill(s), Type: Soft Stop, Pharmacy: CVS/pharmacy# 4752
Ventolin 90 mcg/inh inhalation aerosol: 2 puff(s), INH, QID, PRN: for wheezing, # 1 EA, 0 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752 

Problem list: . 
All Problems (Selected)
Morbid Obesity / ICD-9-CM 278.01 / Confirmed 

Histories 
Past Medical History: . 
No active or resolved past medical history items have been selected or recorded. 
Family History: . 
No family history items have been selected or recorded. 
Procedure history: . 
kidney stones in 1900. 
Social History: . 
	   Alcohol Assessment
	         Never
	   Tobacco Assessment
	         Never
	   Substance Abuse Assessment
	         Never
	   Employment and Education Assessment
	         Employed
	   Home and Environment Assessment
	         Marital status: Married. 

Physical Examination 
VS/Measurements 
Vital Signs 
   Temperature Oral          98.2 DegF  
                         Peripheral Pulse Rate     76 bpm  
                         Pulse Site                Radial artery   
                         Respiratory Rate          20 br/min  
                         Systolic Blood Pressure   146 mmHg  HI  
                         Diastolic Blood Pressure  100 mmHg  HI  
                         Mean Arterial Pressure    115 mmHg  
                         BP Site                   Left arm   
                         Oxygen Saturation         98 %   
, Measurements from flowsheet : Measurements 
   Height                    68.00 in  
                         Weight                    431.20 lb  
                         BSA                       3.06 m2  
                         Body Mass Index           65.56 kg/m2   

General:  Alert and oriented, No acute distress.  
Eye:  Vision unchanged.  
HENT:  Normocephalic, Tympanic membranes are clear, Oral mucosa is moist, No pharyngeal erythema, No sinus tenderness, swollen, boggy nasal mucosa.  
Neck:  Supple, No carotid bruit, No jugular venous distention, No thyromegaly.  
Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal.  
Cardiovascular:  Normal rate, Regular rhythm, No murmur, No gallop, Normal peripheral perfusion, No edema.  
Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.  
Integumentary:  Warm, Dry, Pink, No rash.  
Neurologic:  Alert, Oriented.  
Psychiatric:  Appropriate mood & affect.  

Impression and Plan 
Diagnosis   
HTN (Hypertension), Benign (ICD9 401.1).   
Rhinitis, allergic (ICD9 477.9).   
Obesity (ICD9 278.00).   
Vertigo (ICD9 780.4).   
Ear Problems (ICD9 V41.3).   

Patient Instructions:       Counseled: Patient, Regarding diagnosis, Regarding treatment, Regarding medications, Diet, Activity, Verbalized understanding.  
Summary:  Ear problems likely sec. to allergy or vertigo-antivert prn and nasonex.  referral to surgery for weight loss consultation.  pt to bring copy of recent labs.  referral for ophthalmology.  spent 40 minutes with pt.  
Orders   


Charges (Evaluation and Management):
Return To Office (Requests):
Return to Clinic (Request) (Ordered): Return in 3 months 
Orders.   
Pharmacy:
Bystolic 5 mg oral tablet (Ordered): 1 tab(s) ( 5 mg ), po, daily, # 21 tab(s), 0 Refill(s), Type: Maintenance, samples given to patient (Rx)
Return To Office (Requests):
Return to Clinic (Request) (Ordered): Return in 2 weeks 
Orders.   
Pharmacy:
Flonase 0.05 mg/inh nasal spray (Ordered): 1 spray(s), nasal, daily, # 1 EA, 1 Refill(s), Type: Maintenance, Pharmacy: CVS/pharmacy# 4752 
Orders.   
Charges (Evaluation and Management):
99215 office outpt est 40 min level 5 (Charge) (Completed): Quantity: 1


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## cheermom68 (Feb 7, 2012)

In my opinion, the medical necessity is nowhere near a 99215 and you can't bill based on time because it is not documented appropriately.
LeeAnn


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## jmcpolin (Feb 7, 2012)

the only thing that would support a level 5 here is the exam and thats not enough.


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## ksd (Feb 7, 2012)

I agree with Cheermom.  I would give this a 99213.  No tests were given and the MDM was just not that high.  Giving it the distinction of a 99215 would be putting it on the same level as a patient coming in with respiratory distress receiving a chest x-ray and several breathing treatments.  Somehow just because the Dr. spent 40 minutes talking with the patient does not seem to warrant bumping up 2 E/M levels.


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## perkins05 (Feb 8, 2012)

Thanks everyone for responding...got some push back for doctor on down coding..

Thanks again


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## ksd (Feb 8, 2012)

If you show him the description of the code 99215 he can see where it will state of course
   -Comprehensive history (4 elements)
   -Comprehensice Examination (8 elements)
   -MDM high complexity

    Then comes the description I believe your doctor is getting his 40 minutes from where the AAPC states  _"Usually, the presenting problem(s) are of moderate to high secerity.  *Physicians TYPICALLY spend 40 minutes *face-to-face with the patient and/or family"_

  I usually code ER visits and we often see a patient spend no more than 30 minutes with physician and it be a level 5 (without admission).  Also patient would spend up to about an hour with patient and it would be a level 3.    Appendix C gives several clinical examples of E & M levels.  Incidentally, while scanning the examples, I do not see one where time was mentioned in the example.


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## Evelyn Kim (Feb 13, 2012)

I agree, just because the provider spent 40 minutes with the patient does not justify billing a level 5.  There is no documentation of MDM of high complexity, there is no documentation on consuling or coordination of care that would justify the 40 minutes.


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