# Establishde pt 99213 or 99214?



## Love Coding! (Mar 26, 2008)

Our office uses the SOAP format by dictation. 

Established pt...

This pt has returned to our office for a severe rash on the face that comes and goes, pt feels that this has been going on for 3 months. Was prescribed a topical cream with little improvement. The patient wants to have this looked at. There is no past/family history of skin cancer. This patient works at a nursery and is outside the majority of the time. The review of systems are all negative and noted in the chart.

Subjective - HPI (have met 5 components, severe, face, comes and goes, 3 months and topical cream used) severity, location, timing, duration and modifing factor

Have met all three elements of the HPI 99214

4 - History of present illness
3-  Past, Family and Social history
9 - review of systems (based on our office guidelines)

The following areas have been examined for a skin rash, head, neck, abdomen, back, upper and lower extremities. Other than the head none of these areas have been affected. 

Objective - Exam 8 body areas 99214

1. Rash of the face. Have instructed to use sunscreen and return in two weeks if no improvement. 

Assessment/Plan - MDM low (due to over the counter treatment) 99213

What would this level be? A 99213 or a 99214? I know that with an established office visit you can code by history and exam or by history and medical decision making. 

Would this be accurate, if the MDM is moderate 99214, exam is 2-4 body areas 99213 and the HPI is at a level 99214 could I code it a 99214?

On the flip side of that if the MDM is low 99213, exam was 5-7 body areas 99214 and HPI is 99214 could I code a 99214?

Any help out there would be greatly appreciated!

Denise


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## rthames052006 (Mar 27, 2008)

dscoder74 said:


> Our office uses the SOAP format by dictation.
> 
> Established pt...
> 
> ...



This looks like a level 4(possible level 5) based on what you have stated, the only thing is the R-O-S you say is negative, the skin must be positive if this pt is coming in with a rash right?

You can use any of the 3 key components it doesn't matter which ones as long as you have met/exceeded in 2 of the 3?  

I based the exam on the body areas examined and not the organ systems, based on what you have written.

Even w/o the MDM you'd still have a level 4.

What do others think!


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## Love Coding! (Mar 27, 2008)

*Please anyone help! Established 99213 or 99214 :0)*

Hello, 

I need help with this.  Which is correct in determining a level of service.

Established pt

history and exam, history and MDM or Exam and MDM?  Any help will be appreciated.  Thanks!  

P.S. Thank you rthames052006 for giving me your input!  Greatly appreciated!


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## jennifer.cooper (Mar 30, 2008)

*99213-99214*

To answer your question from an auditors view... Yes there might is a couple of reasons that you office visit would be a 99213 and not 99214.  

1. The following areas have been examined for a skin rash, head, neck, abdomen, back, upper and lower extremities. Other than the head none of these areas have been affected.

         Yes several areas that were looked at however only one body system was reviewed, and when making a decision for the Exam a component it would have to include the review of systems (based CPT guidelines) and not body areas.  

This patient had:
99213- Office Visit

Straightforward History 
Problem focused Exam 
Low MDM

I would recoup the money if I audited this chart for over coding.


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## rthames052006 (Mar 30, 2008)

boyerj said:


> To answer your question from an auditors view... Yes there might is a couple of reasons that you office visit would be a 99213 and not 99214.
> 
> 1. The following areas have been examined for a skin rash, head, neck, abdomen, back, upper and lower extremities. Other than the head none of these areas have been affected.
> 
> ...





Just wondering are you using the 1995 or 1997 exam here.  Maybe if you used the Dermatology exam sheet maybe you'd come out better on the exam.

Just a thought.


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## Love Coding! (Mar 30, 2008)

*99213 or 99214*



rthames052006 said:


> Just wondering are you using the 1995 or 1997 exam here.  Maybe if you used the Dermatology exam sheet maybe you'd come out better on the exam.
> 
> Just a thought.



I based this scenario on 1995 guidelines.  I guess my question would be, determine the level of service by History and Exam, History and MDM or by Exam and MDM????????

Thanks...
 
Denise


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## rthames052006 (Mar 31, 2008)

dscoder74 said:


> I based this scenario on 1995 guidelines.  I guess my question would be, determine the level of service by History and Exam, History and MDM or by Exam and MDM????????
> 
> Thanks...
> 
> Denise



You would base  it on whichever would benefit the provider, you can use whichever 2 you want.


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## Love Coding! (Mar 31, 2008)

Thank you Roxanne!!

Denise :0)


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