# Help with NP E/M



## bamagirl060900 (Sep 16, 2009)

I wanted someone else's opinion on this progress note.  Can this be billed out? My opinion is the three key conponents have not been met or exceeded to bill new patient E/M visit.

*CC: *NP
*History:* here to establish, leaving pediatrician office
*Current Allergies:* NKDA
*Current Meds:* Benadryl
*Current Problems:* No current problems
*Exam:*
*Vitals: *BP Systolic 122, BP Diastolic 76, Pulse: 78, Temperature 97.8
Weight 115, Height 5'5.5", BMI 18.84
*General:* grooming is normal; well developed, well nourished, well hydrated, no apparent distress, average body build
*Eyes: *PERRLA, EOMI, conj & sclerae normal; normal opthalmic exam, lids normal
*ENT:* oropharynx clear, external nose have no scar, lesion, mass, or deformity; nasal mucosa is normal; tympanic membranes and external auditor canals clear; hearing is grossly intact
*Neck:* supple, normal thyroid , no bruits
*Lymphatic:* no lymphadenopathy
*Respiratory:* clear to auscultation bilaterally; auscultation of lungs revealed no rales, rhonchi, or wheezes
*Cardiovascular:* regular rhythm and rate, no murmors, gallops, rubs, regular rhythm, no mumur, or rub
*Gastronintestinal:* soft/NT/ND/BS+; no HSM present; no masses
*Genitourinary: *testicular exam normal; no masses; penilie exam normal; no lesions
*Extremities: *no clubbing, cyanosis, or edema
*Musculoskeletal:*normal ROM and strength
*Neurological:* DTRs 2+ and symmetric bilaterally; nonfocal exam; craial nerves II-XII grossly intact; sensation is; normal motor exam revealed strength 5/5 throughout
*Skin: *no rashes or lesions
*Psychiatric:* normal mood and effect

*Assessment:*
1.) 706.1 Acne
2.) 780.79 Fatigue

*Plan:*
Orders
1.) 99205 - New patient level 5

*Processed Medications:*
None

*Follow Up:*
1.) As needed

*Further*
Will plan to do Hepatitis A vaccine in the near future.


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## LLovett (Sep 16, 2009)

It is most certainly not a level 5 anything.

You have a new patient with no chief complaint so it should be a well care code.

Laura, CPC, CEMC


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## bamagirl060900 (Sep 16, 2009)

Laura, what well care code should be used?


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## LLovett (Sep 16, 2009)

I know the preventive codes are pretty vague but there is really limited history listed so I would personally feel more comfortable with the unlisted 99429 based on this note.

So I would bill 99429, dx V70.0 primary and then the other dxs listed.

This provider needs some education on leveling. Did the EMR level this? Or did he choose the level? This note looks very similar to the Praxis EMR one of my providers uses. He doesn't use the leveling function they offer, for a few reasons, so I have never seen what happens when you do.

Laura, CPC, CEMC


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## bamagirl060900 (Sep 16, 2009)

Laura
Thank you for your help, it is greatly appreciated.


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## FTessaBartels (Sep 16, 2009)

*History*

Before using the unlisted, I'd go back to the physician for some clarification. It's possible that he has obtained patient's old records and that would suffice for a history that would meet 99385.  He should amend his note to reflect that history if appropriate.

Also check if you have a new patient questionaire that may have been completed.  The physician should also sign and date this form as having been reviewed (and mention it in his dictated note).

One of my greatest frustrations is getting doctors to document the negatives that they ask about but don't bother recording.

F Tessa Bartels, CPC, CEMC


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