# HELP!! E/M Level for New Pt ?!?



## anne32 (Apr 4, 2014)

Please read the note below. I am not very good at E/M coding and I need help. The provider has a site she calculates her E/M levels and this note is coming out as a 99203. (This is a new patient btw.) She spent about an hour with this patient and is confused as to why it isn't a 99204. HELP!!!




Current Medications 
None 



Past Medical History 
Term birth, BW 6-14, healthy, breastfed 
First 10 years - healthy, rare OM, no wheezing, no asthma 
First grade - learning disability - IEP. Then, homeschooled for 2nd and 3rd grade 
12/2013 - . Torus fracture right radius 
2013 & 2014 Seen by ----------
2013 & 2014 - Anxiety, abdominal pain (AM & after lunch), gassiness, constipation & diarrhea 
2013- Missed 30 days of school 


Surgical History 
Denies Past Surgical History 


Family History 
Father: alive No GI problems  
Mother: alive No GI problems  
Siblings: No GI illness  
3 brother(s) , 1 sister(s) .  
Possible GERD in the family. No known inflammatory bowel disease. 


Social History 
Lives With: Parents, and Siblings. 
Language: English. 
Country of Birth: U.S. 
Pediatric Home safety measures: has smoke detector. 
Tobacco Exposure: No. 
Animal Exposures: no pets in the home.  

Allergies 
N.K.D.A. 


Hospitalization/Major Diagnostic Procedure 
Denies Past Hospitalization 


Review of Systems 
CC basic:  
       Sick contacts none.  Brought by mother.     


 Reason for Appointment 
1. pediactic Evaluation  


History of Present Illness 
Depression Screening:  
       PHQ-9  Thoughts that you would be better off dead, or of hurting yourself in some way  Not at all, Total Score  10, Intepretation  Moderate Depression. 
Pediatric Mood :  
       Parents primary concern: Possible anxiety and abdominal pain. Mother wants to know more about why Morgan has abdominal pain. Missed school because of stomach problems - dx irritable bowel, or may have other issues. Diet is good, constipation. Goes to the BR a lot, but c/o constipation & diarrhea. Parental report on General Mood: She is not getting the right help for reading. She has not been diagnosed with dyslexia, but mother has dyslexia, and would like a multisensory approach. . School issues: LD - dyslexic, in resource. WISC V. Problems: Stomach pain before school, then the night before. Mother would like to know if there is a physical reason for the problems. She has vomited twice at school on one day. Normally, her tummy pain starts in the morning or after lunch. Pain is better is she eats fruit smoothies and green smoothies. Worse with school foods w/ whole wheat. She has excess burping, gas. No bloating. Sometimes it is better after going to the bathroom Sometimes is shopping, and will beg to go home with stomach pain. Mid to upper. 
Sick:  
       c/o concerns about Prior evaluation 3/17/2014 -Child was evaluated 2 months prior diagnosed with, fluctuating constipation/diarrhea abdominal pain bloating gassiness improved with defecation. Recommendation increase fiber increased fluid. Patient has been instituting fiber fluid without significant improvement in abdominal pain and bloating. Assessment - Anxiety from learning disability; request pediatric psych eval potential treatment of anxiety.  

Vital Signs 
Pain scale 0, Wt 55.0 lbs, Ht 50.87 in, BMI Percentile 12.42, BMI 14.94, BP 120/72, Temp 97.7, HR 109, SaO2 97, Ht Percentile 3.98, Wt Percentile 2.19. 

Examination 
CC Pediatric Exam:
       GENERAL APPEARANCE: Very petite, alert, quiet and pleasant girl who is cooperative with the exam.  SKIN: no rashes, no skin lesions.  HEAD: normocephalic.  EYES: normal, sclera/conjunctiva clear.  EARS: TMs: pearly gray, with good light reflection.  NOSE: nares patent and clear, mucosa normal.  ORAL CAVITY: moist mucous membranes, tonsils normal, pharynx without erythema or exudate.  NECK: supple, no lymphadenopathy.  HEART: RRR, no murmurs.  LUNGS: clear, equal breath sounds bilaterally.  ABDOMEN:  soft, nontender, no masses.  EXTREMITIES: moving all extremities equally.  NEUROLOGIC EXAM: non-focal.  OTHER Interpretation of drawing: She comes from a well-anchored situation. Whatever the learning disabilities are, they create a appearance of being of being less mature in manner (more like an 8.5 year old girl). She has a certain sense of helplessness in terms of her ability to cope, but 'covers up' with a cheery outlook. She is generally accessible to people, is not overly anxious or agitated. She seems to have some low self esteem and feels powerless, but still feels secure in her world and connected to the people who love her. Second picture does show some signs of depression showing up, in that the dogs have sad faces, even though the big, center bear has a happy face.  


Assessments 
1. Abdominal pain, periumbilic - 789.05 (Primary) 
2. Abdominal pain, chronic, generalized - 789.07 
3. Flatulence, eructation, and gas pain - 787.3, etiology unclear. First thoughts: Constipation, Giardia, lactose intolerance and celiac disease can all cause these symptoms. 
4. Learning disabilities - 315.2, reading level > 3 years delayed, math delay 
5. School avoidance - V62.3, secondary to physiologic abdominal pain or functional abd pain vs. anxiety 

Treatment 
1. Abdominal pain, periumbilic  
Start Zantac (Ranitidine) liquid, 15 mg/mL, 5 ml, orally, BID, 30 days, 300 ml, Refills 3
     LAB: Stool- Giardia Antigen
     LAB: Complete Metabolic Panel (Ordered for 03/31/2014)  Normal     Calcium, Serum 9.7  
     Glucose, Serum 106  
     BUN 15  
     Protein, Total, Serum 7.2  
     Albumin, Serum 4.4  
     Bilirubin, Total 0.4  
     Alkaline Phosphatase, S 375  
     AST (SGOT) 13  
     Potassium, Serum 4.1  
     Sodium, Serum 140  
     Chloride, Serum 109  
     Creatinine, Serum 0.61  
     ALT (SGPT) 22  
     Carbon Dioxide, Total 24  
             140 4.1 109 24 7 106 15 0.61 9.7 7.2 4.4 0.4 375 13 22 . 

     LAB: TSH (Ordered for 03/31/2014)  Normal 1.94     TSH 1.94  


     LAB: Celiac Disease Panel (Ordered for 03/31/2014)
     LAB: Sedimentation Rate-Westergren (Ordered for 03/31/2014)  1     Sedimentation Rate-Westergren 1  


     LAB: Stool- Occult Blood  Negative     OCCULT BLOOD, STOOL neg  

     LAB: H. PYLORI AG, STOOL
     LAB: Cryotosporidium antigen

FUNCTIONAL ABDOMINAL PAIN 
1. Regular meals, including breakfast, and good nutrition are important 
Breakfast everyday, plus 5 servings of fruit or vegetables 
Avoid soda, chocolate, chips, Cheetos and other non-nutritious foods 
If drinking milk makes the abdominal pain worse, then try Lactaid Milk or soy milk. 
Consider other medications and health foods that have been shown to help with abdominal pain; 
Lactobacillus GG (Culturelle) or L. reuteri, which have been studied. Other Lactobacillus combinations may also be helpful, if the first two are not availble or are too expensive. 
Medication - Cyproheptadine - has been helpful for some children 
Peppermint capsules have helped some children. 
Relaation techiques may be helpful 
If your child is not improving, keep an abdominal pain and diet diary and return to clinic for further evaluation. Also, watch for signs of constipation, which is very common, and treat if present.    

2. Abdominal pain, chronic, generalized  
Will plan to check for common causes, and consider KUB for constipation. She was not distended today. GI referral if abdominal pain does not improve.    

3. Learning disabilities  
Recommend WISC IV to evaluate reasoning, short term memory, non-verbal learning, etc.    

4. School avoidance  
Previously, anxiety thought to be the source of abdominal pain and missed school. Patient denies being bullied, but learning disorders put her at risk. Anxiety is a common cause of abdominal pain; If medical evaluation does not find a cause for pain, and a trial of dairy-free/glutin free foods does not help, then a trial of an anti-anxiety medication would be a reasonable next step.    



Preventive Medicine 
CC sick:  F/u for new symptoms,  poor oral intake, increased crying or pain, difficulty breathing, high fevers, weakness, changes, or if worse.   
Face to face time with patient > 50 minutes, Education of patient/caregiver and co-ordination of care comprised 50% of the face-to-face appointment time.


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## dolly_deleon (Apr 4, 2014)

From reading the note, I would give this one a level 4 as well, 99204.  To better help you level E/M encounters you can go to the Novitas website, www.novitas-solutions.com, and print out/download a worksheet.  This tool is very helpful in leveling E/M encounters.


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## Bnevin (Apr 4, 2014)

Look At the Review of Systems,  this is a very common missed area and the reason for the lower level code.


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## OCD_coder (Apr 4, 2014)

I agree with Bnevin in that there is not enough ROS to support a 99204.  A comprehensive 10 organ system review is needed to support that high of an E&M level and there are only Psych and GI documented.  

Time documentation is insufficient to support a 99204 also as Total face to face time is not documented and it is always best practice to use specific minute when documenting the counseling time separately.


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## cheermom68 (Apr 11, 2014)

REview of systems is insufficient


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## wfriddle (Apr 18, 2014)

I am confused by these statements about the ROS. I too have not had a lot of experience with E/M coding so I am trying to better clarify my understanding. Can the systems reviewed in the exam not be counted for the ROS? I see several systems reviewed that I would count as an Extended Review of Systems. Where else would you look for these?


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## OCD_coder (Apr 18, 2014)

wfriddle;

ROS can only be subjective information, it's the information the provider gathers from the patient typically in the patients own words.  So you cannot use information in the Exam (Objective) to credit to ROS.

The exam is the findings in the providers words when they evaluate various organ systems relating to the presenting problem.

So the information documented is deficient for ROS based on what was documented.

Hope this helps.  Here is the CMS E&M Guidelines that are helpful when starting out learning E&M scoring.
https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-icn006764.pdf


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## wfriddle (Apr 18, 2014)

Thank you! That is very helpful!


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## Cynthia Hughes (Apr 21, 2014)

The note states, Face to face time with patient > 50 minutes, Education of patient/caregiver and co-ordination of care comprised 50% of the face-to-face appointment time. 

The physician likely intended to say that counseling and/or coordination of care dominated the encounter (ie, more than 50% of the face-to-face appointment time was spent in counseling/coordinating care). This would have supported 99204 regardless of key components. Likewise, had actual time of the E/M service been noted, there might have been support for prolonged services (99354) in addition to code 99203.

As noted by others, the ROS does not support a comprehensive history needed to report 99204. This could have been obtained by auxiliary staff or completed by the patient and reviewed by the physician or other QHP. 

Definitely suggest reviewing CPT instructions and policies from your common payers regarding time-based billing.


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## dixechik (May 9, 2014)

*99202*

I would only give a 99202 as the only ROS is the Allergies:NKDA  And as far as time.  You need all three elements.  The time, greater than 50% and what you did to coordinate and counsel care.


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