# E&M Level Help



## jmcalhaney (Feb 27, 2013)

I was wondering if I could get opinions on what level of service should be billed in this case.

HPI:  70 yo male with a past history significant for HTN, obesity, and OSA on CPAP.  He was diagnosed with PE in Aug '11.  He also had an abnormal scan with small lung nodules and nonpathologic lymphadenopathy.  The patient was admitted to the hospital in Nov 2012 with CHF, cardiomyopathy, and pleural effusion.  Pulmonary was consulted and the pt was evaluated by Dr. ******.  He did not think it was malignant, but his lymph nodes were related to CHF.  The patient is here today for a follow up.  He says he has been doing great.  No breathing problems at all.  No SOB.  No Fever of Chills.  No weight loss.  Actually he gained 7 pounds since last seen.

ROS:  As per the HPI;  otherwise negative

Current Meds:  Reviewed

Allergies: NKDA

Exam

Appearance:  Patient is awake, alert, and oriented in no apparent distress
Vitals:  BP is 220/110; HR is 70; RR is 16; Temp is 98.2; Weight is 280
HEENT:  Head atraumatic, normocephalic.  Anicteric sclerae. EOMI.  Oropharynx score is 4.
Neck: supple
Lungs:  clear to auscultation bilaterally
Heart:  S1, S2, RRR
Abdomen:  Soft, nontender.  Bowel Sounds are positive
Lower Extremities:  Trace Edema 
Skin:  Warm and Dry
Neurologic:  No focal deficit

DATA REVIEW:  A CT scan of the chest was done on 1/9/13 with IV contrast showing small noncalcified pulmonary nodules, all apprearing stable.  Recommend progress study in 6 months.  

Impression:
1.  Pulmonary nodules, which are all stable and less than 6 mm in diameter.  
2.  Malignant HTN.  The patient has very high BP.  I advised him to go to the ER so they can control it given all his comorbidities.  Patient refused.  He prefers to see Dr. *****.  We contacted Dr. ***** and he will be seen now.  Our respiratory technician walked him to Dr. ******'s office.
3.  Obstructive Sleep Apnea.  He is very compliant with his CPAP
4.  Obesity.  Weight loss was discussed with the patient
5.  The patient will follow up in the pulmonary office in 6 months to review CT scan.


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## sullivak (Mar 1, 2013)

What are you asking about specifically? What are your ideas as to how it should be coded?


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## jmcalhaney (Mar 6, 2013)

sullivak said:


> What are you asking about specifically? What are your ideas as to how it should be coded?



I am only worried about the E&M level and I believe it is a 99214.  The physician does a comprehensive History and Exam on almost every single patient and coded this as a 99215.  I feel that if the patient came in with no complaints and was doing well, you will not have a 99215 visit.  I am unsure if his BP will put him in a high risk category.  I am also confused as to how to add my diagnosis points.  This physician is a pulmonologist and will sometimes write down as many as 15 diagnosis for a single patient.


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## sullivak (Mar 6, 2013)

Here's what I get: 
Physician covered 3 chronic illnesses - Extended HPI if use 97 guidelines.
ROS: Complete, although the wording should be something like "reviewed and negative"
PFSH: Detailed (only did PMH)
History - Detailed

Exam: 
Const 2 points,
eyes 2 points
ENT 1 point
Neck 1 point
Lung 1 point
CV - 2 points
GI - 1 point
Skin - 1 point
neuro - 1 point
12 points total - Detailed Exam

MDM
DMO, 2 established stable problems, 1 new problem - malignant HTN prompting physician to send pt to the ER.  Total of 6 points.
Data: radiology reviewed - 1 point
Risk: High - malignant HTN is life threatening.
MDM = high

Now by 97g this would be 99214
Per 95g this would be 99215
History: Detailed
Exam: 8 organ systems- comprehensive
MDM: High

Hope that helps!


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## jmcalhaney (Apr 2, 2013)

sullivak said:


> Here's what I get:
> Physician covered 3 chronic illnesses - Extended HPI if use 97 guidelines.
> ROS: Complete, although the wording should be something like "reviewed and negative"
> PFSH: Detailed (only did PMH)
> ...



Thanks for your response.  I also agree that he should state something other than what is stated for his ROS.  The medical necessity is what really gets me in these situations where the Physician is documenting a comprehensive exam for every single patient.


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