# Level Four (99214)?



## daniel (Oct 2, 2008)

Base this on History and MDM.
What level.

She is a 56-year old female presenting with a couple of weeks of a heavy sensation in her chest, particularly on work days when she is at work. She works for a dentist. She does yoga and other exercises, which actually relieves her symptoms. She is not having any radiation of pain or respiratory symptoms. She does have a history of hyperlipidmia, however, and is on Zetia.

She denies any shortness of breath, wheezing, cough, etc.


Ekg ordered-reviewed: normal sinus rhythm. There is no change from November 2, 2005.


Assement: Chest tightness, most likely stress-related

Recommend a trial of Lexapro and continuing with excersise. Will follow up in about three weeks, sooner if her symptoms escalate or they become exertionally-related.


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## missy874 (Oct 2, 2008)

Based on HPI and MDM, I would only charge a 99213. The history seems to be expanded problem-focused and the medical decision making seems to fall within the low to moderate range.


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## ARCPC9491 (Oct 2, 2008)

daniel said:


> Base this on History and MDM.
> What level.
> 
> She is a 56-year old female presenting with a couple of weeks of a heavy sensation in her chest, particularly on work days when she is at work. She works for a dentist. She does yoga and other exercises, which actually relieves her symptoms. She is not having any radiation of pain or respiratory symptoms. She does have a history of hyperlipidmia, however, and is on Zetia.
> ...




On quick audit I get:
Duration = 3 weeks
Quality = "heavy"
Location = chest
Context = while at work
Modifying Factor = Exercising
Signs/Symptoms = No radiating pain
_....way to quantify HPI elements!! 4+_

PFSH: Social and Past History Documented - 2/3

ROS: Respiratory

History: Expanded Problem Focused

MDM: 
New problem, no work up
Data, Review EKG
Risk - Moderate

Overall MDM: Moderate

I tried to squeeze one more ROS, that would have given you you're 99214, but it's not there!! 

So, you've got a 99213


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## pamtienter (Oct 2, 2008)

Could you use "not having any radiation of pain" as cardiovascular ROS instead of an associated sign/symptom and get an extended ROS?


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## daniel (Oct 2, 2008)

I over looked and forgot to add, the M.A. Put in the top of the progress note. 
Medciation allerigies: Demerol.

So that gives me my Extended ROS. For my four (99214).
Right.


Thank For your input

Daniel,CPC


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