# High level E/M?



## losborn (Aug 25, 2010)

Established patient with four problems - all of them follow-ups.  Progress notes a short assesment of each one, and a treatment plan.  One is a toe nail Bx, one gets an injection, the other two are treated topically.  
Doc says that because there are so many, he should get a 99215.  I've got no real HPI or ROS; one exam: skin.  Not much detail.

How should I code the E/M here?

Thanks in advance

Lin  
CPC


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## cmcgarry (Aug 26, 2010)

losborn said:


> Established patient with four problems - all of them follow-ups.  Progress notes a short assesment of each one, and a treatment plan.  One is a toe nail Bx, one gets an injection, the other two are treated topically.
> Doc says that because there are so many, he should get a 99215.  I've got no real HPI or ROS; one exam: skin.  Not much detail.
> 
> How should I code the E/M here?
> ...



Could you possibly post the de-identified note?  Without knowing how thorough of an exam, it's hard to come up with a level.  Also, the number of diagnoses does not automatically make any E/M a level 5 - how much data was reviewed, and what was the risk?  Thanks,


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## AB87 (Sep 24, 2010)

CPT says "High Severity" for a 99215 Meaning some kind of life or death situation but you have to have alot of HPI and Exam for it to qualify. Not only that the MDM had to be some kind of Heart attack or some kind of Stroke during the visit and being sent to the ER for a "High Severity" condition. Just my opinion on this one


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## AB87 (Sep 24, 2010)

i would maybe use a 99213 since its 4 problems then u have a procedure(s) with the visit


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