# 99213 or 99214?



## MMAYCOCK (Jul 21, 2010)

Hi

Would the below note be considered 99213? If so, what elements are missing or inadequate to meet the standard for 99214? This provider is a specialist and the system coder puts everything at 99213. We are wondering if it is coding correctly.

Thank you

*1. Back pain. 2. Neck pain.  

 HPI: 
   Lumbar Spine/Lower Back:  
       Patient is here today for evalutaion of his back pain. He stated that the pain radiates into his groin and his legs and he has numbness in his legs and feet. Patient also stated that he has pain in his neck that radiates into his arms. He stated that he has numbness in his arms and hands as well. On a scale of 0-10 with 0 being the least amount of pain and 10 being the worst amount of pain, he stated that today his pain level is an 8. He recently had to work on his car and was lying on the concrete. he had a hard time getting back up and ever since then, he has been having more neck pain and arm pain. that was 1 week ago. 

 Medications: OxyContin 40 mg 1 tab(s) bid, Norco 325 mg-10 mg 1 tab(s) q 4 H, Neurontin 400 mg 1 cap(s) qhs 

 Allergies: Morphine.  


Objective:

 Vitals: BP sitting 146/93, Pulse sitting 64, RR 18, Temp 97.7, Ht 71, Wt 305, BMI 42.53. 

 Examination: 
   Lumbar Spine/Lower back: 
       Reflexes: Normal.  Sensation: Within normal limits.  Provocative Tests: ..  Neurologically Stable: No upper motor neuron signs are seen.  Location: Lower back.  ROM: Within normal limits, Some discomfort is present at extremes of the range of motion.  

   Cervical Spine/Neck: 
       ROM: of neck and both upper extremities appear to be within normal limits., Some discomfort is present at extremes of the range of motion..  Location Neck.  Reflexes: normal.  Sensations: Within normal limits.  Provocative Tests: are not performed today.  Neurologically Stable: No upper motor neuron signs are seen.  

   Items reviewed: 
       Radiology Films not reviewed.  Radiology Films not reviewed.  Medical records reviewed.  Medical records reviewed.  Narcotic drug policy is in chart was reviewed with patient today .  Narcotic drug policy is in chart was reviewed with patient today .  Home exercise program was reviewed and discussed with the patient.  Home exercise program was reviewed and discussed with the patient.  Current work restrictions are not applicable as patient is not working.  Current work restrictions are not applicable as patient is not working.  




Assessment:

 Assessment: 
1. LUMBAR DISC DEGENERATION - 722.52 (Primary)  
2. CERVICAL DISC DEGENERATION - 722.4  
3. Chronic pain syndrome - 338.4  
4. PAIN (SHOULDER) - 719.41  
5. POST LAMINECTOMY SYNDROME - 722.83  
6. Radicular syndrome of lower limbs - 724.4  
7. DISC DIS NEC/NOS-LUMBAR - 722.93  
8. Low back pain - 724.2  
9. Cervical arthritis - 721.0  
10. Radicular syndrome of upper limbs - 723.4  
11. LUMBAR STENOSIS - 724.02   

Plan:

 1. Cervical arthritis  
I advised patient to give it another couple weeks for the neck to recover from the stress of him laying on the concrete to fix his car. If at that time he is still not improving, I will get an MRI. Medications are refilled today. NDP is renewed.     

2. Others   Refill OxyContin tablet, extended release, 40 mg, orally, 60, 1 tab(s), bid, 30 day(s), Refills 0 ;  Refill Norco tablet, 325 mg-10 mg, orally, 120, 1 tab(s), q 4 H, 30 day(s), Refills 0 .    


 Immunizations:   

 Labs:    
 Follow Up: 4 Weeks *


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## Orthocoderpgu (Jul 21, 2010)

First of all: submitting everything as a 99213 is a red flag to payors. It tells them you don't know what your doing and that what your submitting is probably inaccurate. Your HPI is lacking. I get four HPI elements but no ROS elements. By 97 rules, this is not a detailed exam. By 95, who knows. No one can tell you the difference between a "limited exam" and an "extended exam" with any certainty. You need a detailed exam to get this to 99214. Your MDM is Moderate due to two stable Dx's. I would give this a PF HPI, EPF Exam and Mod MDM which would be a 99213. You want a 99214, beef up HPI and Exam. My two cents anyway.


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## rthames052006 (Aug 27, 2010)

qcoder said:


> First of all: submitting everything as a 99213 is a red flag to payors. It tells them you don't know what your doing and that what your submitting is probably inaccurate. Your HPI is lacking. I get four HPI elements but no ROS elements. By 97 rules, this is not a detailed exam. By 95, who knows. No one can tell you the difference between a "limited exam" and an "extended exam" with any certainty. You need a detailed exam to get this to 99214. Your MDM is Moderate due to two stable Dx's. I would give this a PF HPI, EPF Exam and Mod MDM which would be a 99213. You want a 99214, beef up HPI and Exam. My two cents anyway.



Depending upon who your carrier is.... you could have 1 ROS .  My local carrier is Highmark Medicare and we can count the back pain as ros as well.


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## sbicknell (Aug 27, 2010)

location:  lower back
quality: radiates to groin
Assoc S&S:  pain in neck
Severity:  8

MS ROS:  all info about the car...1 week ago
Neuro ROS:  numbness of arms and feet

PH:  current meds

Exam
vitals
reflexes
sensation
neuro
ROM back
ROM neck
ROM RUE
ROM LUE

MDM
2-0-mod

So I get a 99213 ---  Detailed History, EXP exam and Low MDM

I find the 11 DX curious.


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## dwaldman (Aug 30, 2010)

The dx could be broken down for reporting purposes: 722.83 722.52 722.93 721.0 since the ICD-9 book and Coding Clinic state that codes starting with 723 or 724 are signs are symptoms and are considered included in the underlying conditions. It would be better if he could state it like: radiculitis due to disc bulging and degeneration. And what symptoms are associated with the post-laminectomy syndrome. I would inquire about 338.4 chronic pain syndrome. I usually see 338.29 other chronic pain used more often.


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