# I need help on E/M level. Please



## MsMaddy (Nov 4, 2009)

My doctor has created this new template and wants to know how can we make this a leve high level. I would like to know what is the highest level you can go with this. Please see below: KEEP IN MIND WE DO HAVE STICKER ON THE SIDE OF THE CHART THAT THE MA RECORDS VITAL SIGNS, WEIGHT. 


VAGINITIS


______DAYS                             ______F

VAG. BLEED NOW  Y N                TENDERNESS Y N  ABDOM. PELVIC VAGINAL
ITCH                  Y N                 ERYTHEMA   Y N 
URETHRAL PAIN D/C Y N              SECRETION  Y N 
DISCHARGE         Y N  COLOR____                        COLOR____
                               CONSISTENCY_____            CONSISTENCY____
                               ODOR     Y  N                     WHIFF     Y N

ABDOMINAL PAIN Y N                KOH POSITIVE Y N      ___+/4+
FEVER               Y N                CLUE CELLS     Y N      ___+/4+
MEDS TRIED       Y N                VAGINAL BACTERI Y N  ___+/4+
                                                          WBC Y N     ___+/4+
                                                          TRIICH Y N  ___+/4+
                                                          RBC  Y N     ___+/4+
                                                          PH   Y N     ___+/4+

BACTERIAL VAGINOSIS   VAG MONILIASIS  VULVOVAGINAL MONILIASIS TRICHOMONIASIS  PHYSIOLOGIC DISCHARGE  ATROPHIC CONTACT DERMAT.
CYTOLYTIC VAGINOSIS

BUTOCONAZOLE PV  CLINDAMYCIN P.O. PV  CLOTRIMAZOLE PV FLUCONAZOLE PO METRONIDAZOLE P.O PV  MICONZOLE PV  NYSTATIN PV TOPICAL  TERCONAZOLE PV  TERCONAZOLE PV TINDAZOLE  TIOCONAZOLE PV  OTHER ________

HORMONE PV PO TOPICAL ________   TOPICAL STERIOD __________

____MG  ONE TIME  QHS QDAY BID   X____DAYS  WEEKLY X____

CBC ESR CRP  URINE GC/ CHLAMYDIA   RTO _______


THANKS IN ADVANCE
MSMADDY


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## 18slugger (Nov 4, 2009)

I dont think you will be able to up the E/M level becuase it will be base on the decision making and not just the ROS HPI and exam.


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## FTessaBartels (Nov 4, 2009)

*Where is the exam?*

This is *not* my area of expertise (OB/GYN) but ...

I do *not* see *any* exam here other than your statement that you have a STICKER ON THE SIDE OF THE CHART THAT THE MA RECORDS VITAL SIGNS, WEIGHT  But maybe I'm misinterpreting some of this because of the way it is organized.

I'm concerned, too, that you appear to have a diagnosis as your chief complaint. How does the *patient *know she has vaginitis?  It is more likely that she  is complaining of symptoms, not a diagnosis.

Developing a template for commonly seen problems can be a good way to ensure you have documented everything that is *medically necessary*.

I would start by dividing my template into HISTORY / EXAM / LABS & XRAYS / ASSESSMENT&PLAN sections.

Then I'd list the types of information that would be most relevant. If you follow the CPT guidelines, as well as 1997 or 1995 guidelines for determining levels of E/M you can include enough information on the form to allow the visit to be coded at the highest level.  BUT ... *BIG BUT* ... this still has to be medically necessary. 

A complaint of itching and discharge might be a yeast infection (which could be treated with OTC meds), or might be something much more serious. A head-to-toe exam and detailed history might not be medically necessary for the first scenario. The doctor should perform the service that is medically necessary, and then document what was performed. That documentation will lead the coder to assign the correct level of service.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## MsMaddy (Nov 4, 2009)

So what E/M level do you think would be appropriate ? I think the highest he could go is 99213.

Thanks 
MsMaddy


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