# Another question



## julia9723 (Nov 16, 2011)

I know that the e/m code is driven by the MDM.  I have an GYN doctor that did an annual exam.  She did a  detail history and her exam was detail but the MDM was low complexity.  She coded the visit as a 99214.  Technically that is right, but because the MDM was a low complexity did she overcode?


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## Love Coding! (Nov 16, 2011)

julia9723 said:


> I know that the e/m code is driven by the MDM.  I have an GYN doctor that did an annual exam.  She did a  detail history and her exam was detail but the MDM was low complexity.  She coded the visit as a 99214.  Technically that is right, but because the MDM was a low complexity did she overcode?



It's hard to determine without seeing the actual note.  Could you post it eliminating the personal demographics?

Thank you, I was curious..


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## julia9723 (Nov 16, 2011)

Is there a section your interested in seeing.  We have EHR and the report is 4 pages long.  If you give me your email address, I can send it to you.  I would appreciate any help I can get.


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## Love Coding! (Nov 16, 2011)

julia9723 said:


> Is there a section your interested in seeing.  We have EHR and the report is 4 pages long.  If you give me your email address, I can send it to you.  I would appreciate any help I can get.



I'll send you a message do not want to put my email address out there! 

Hope I can help...


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## zanalee (Nov 17, 2011)

if this is an establish ov than is 2 out 3 requirements, she does have a 99214...


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## FTessaBartels (Nov 18, 2011)

*"annual exam" is Preventive!*

You say the patient was seen for an annual exam. This is a preventive visit. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## julia9723 (Nov 21, 2011)

If the doctor only did the pap smear and no other preventative care, would you still coded it as a preventative visit?  

Also, how many HPI do you see?

On set 2 years ago, Previous medication therapy included Avodart. The result of the treatment was good.  The problem is improving. Pertinent negatives include intermittent stream, slow stream, splitting stream or strains to urinate.  IPSS today was 6, Qol2

CC: year old male presents for bhp.

Thank you for all your help


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## mitchellde (Nov 21, 2011)

i am in agreementwith Tessa, if this was the precentive exam then use a preventive code notthe ov level.


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