# so, what level do you come up with?



## dmaec (Aug 11, 2008)

Below is an E/M visit that I had to audit and score out.  If anyone has the time to score this out and let me know what they come up with (and how) I'd sure appreciate it. It is the exact note I reviewed to determine my level.  This documentation has become the hot topic around here as far as what level it is, and why.  I'll be bringing this note and my scoring E/M sheet to an E/M training class on August 28th.  It will be interesting to see what they think too!  Thanks for any input you have! I realize you'll probably have a few questions right off the bat, but please (that's part of my point), just work with what is written below.  THANKS TONS!
SUBJECTIVE:  Patient comes today with complaints of stabbing right ear pain and some sinus pain and pressure. He feels that this ear pain is constant over the past few days. He complains that he has had an ear infection two times for the past few years. He has tried over the counter Excedrin for the pain and he does get some relief from this. In the past for his sinuses he has tried nasal saline spray, has not done this on any consistent basis. He has had no fever, rhinorrhea or cough. He has had these symptoms on and off for the past month but worse in the last few days. He reports that he is normally healthy. No chronic diseases such as diabetes, heart, lung or kidney problems. Diabetes does run in his family and 20 years ago he passed out from hypoglycemia so he does make it a point to eat small frequent meals so this does not happen again. He has not had a routine physical in 3-5 years. 

Routine medications: Multivitamin.

Allergies: No known medication allergies.

Risk factors: Smokes two packs per day for 37 years. Is contemplating quitting. Has quit in the past for as long as six months. This was a couple years ago. His wife is a smoker, she refused to smoke outside of the house. This made it difficult for him while he was attempting to quit and he subsequently resumed smoking again.   

OBJECTIVE:  Vital signs: Weight 218.6#, Height 58", Blood pressure 124/78, Temp 97.6, Pulse 76, Respirations 20.  
Constitutional: Pleasant, alert and oriented X3, forty-two year old white male in no acute distress.
HEENT: 
Head: Atraumatic, normocephalic.
Eyes: Sclerae clear, conjunctivae non injected. No drainage, no eyelid inflammation or swelling. Pupils equal, round and reactive to light and accommodation. Funduscopic exam essentially within normal limits. 
Ears: External auditory canals patent. Tympanic membranes pearly gray, bony landmarks visualized. Light reflex intact and clear fluid noted behind the tympanic membranes. 
Nose: Nasal mucosa erythematous with brown discoloration from nicotine. Swollen pharynx posterior mildly injected worse on the right. Tonsils non swollen no exudates. Uvula rises midline. Swallowing intact. 
Neck: Supple, full range of motion, no lymphadenopathy.
Sinuses: Non tender to palpation, frontal and maxillary. No periorbital swelling. No facial swelling or erythema.

ASSESSMENT:  1) Eustachian tube dysfunction.
               2) Pharyngitis. 
               3) Nasal congestion.
               4) Tobacco addiction.    

PLAN:  Discussion with patient that the best way to improve his symptoms overall is for him to quit smoking. This was discussed with patient, he has been contemplating trying to quit and was pleased with his prior success. Has considered using Chantix. Risks and benefits of this was discussed today, a prescription was written for a starter pack with two refills. Would have him do symptomatic measures for the sore throat, including warm salt water gargles, ibuprofen or Tylenol as needed. For his nasal congestion would have him use Afrin nasal spray for no more than three days. Was cautioned regarding rebound congestion if he used this for longer than three days. Was also given a nasal steroid. Have him use the Afrin first, then wait an hour and use the nasal steroid. If the nasal steroid spray is helping him following a week and a half use he can continue using this two puffs each nostril everyday. If it is not helping, he should stop it. He verbalizes understanding and agreement with plan. Would also recommend that he follow up for routine preventative health maintenance.


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## Lisa Bledsoe (Aug 11, 2008)

Donna - I was not clear if this was an established or new patient...  For established I came up with 99214 (detailed history and exam, and moderate MDM); for new I came up with 99203.  

What did you get and what is the controversy?


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## dmaec (Aug 11, 2008)

thanks Lisa - yes, not knowing new/est was part of the problem.  Patient is new - I came up with 99214 also for est but 99202 for new.  I have EPF History - DET Exam - MOD MDM.

oops - sorry (I have two issue E/M's that I'm working on) on this one, not knowing new or est was part of the problem- I acutally got EPF History and Exam (not detailed exam on this one)  - and MDM MOD.
so, really - I got a 99213 est and 99202 new for this posted E/M visit.

the issue was it was first coded as an established patient (coded from the note only).  Provider then let us know it was a new patient - and she wanted it a 99203, I come up with 99202.  
HPI x3- Pain - ear/sinus, duration, modifying factor 
ROS x1- Allergy
PFSH x2- Previous Medical - Family
For Exam - I have Const, neck, eyes, ENT mouth - 
MDM - moderate (new problem w/prescription)

so, are you getting more of an HPI and EXAM?  are you using the "negative" responses for under your HPI?  Even getting the HPI up to detail, (using negative associated signs/symptoms) or the ROS 2-9 systems (using negatives cough/rhinorrhea) - I can see where those can go higher - but I still don't see a Detailed Exam (which brings the new patient down to a 99202) what did you get for your EXAM?
thanks again!


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## Lisa Bledsoe (Aug 11, 2008)

For the HPI I have location (ear), quality (stabbing pain), timing (constant), duration (past few days); ROS I have constitutional (no fever) and ENT (no rhinorrhea or cough) - pertinent negatives; PFSH I have past hx (no chronic diseases/also that he has had ear inf twice in the past few years); family hx (diabetes not running in the family); social - smoker. 

Exam I scored 4 organ systems = detailed because of the detailed nature of the ENT exam.


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## FTessaBartels (Aug 11, 2008)

*History*

Donna,
When I look at the History I marked "new" because the MD states - no physicial in 3-5 years. I guess I was assuming ... bad sign .. (at least I assumed correctly, this time) ... LOL

Okay ... seems like history is your main problem/controversy ...
Here's what I get:
Chief complaint: ear and sinus pain
HPI:  Location (right ear), Quality (stabbing pain), Timing (constant), Duration (several days), Modifying factors (Excedrin w/ some relief)

Everything else I count towards ROS ... and they're all negative:
fever, rhinorrhea, cough, diabetes (endocrine), heart, lung, kidney, allergy

Family history of DM
Past med history:  hypoglycemia
Social history: pt is smoker and wife smokes

I'd get 99203

F Tessa Bartels, CPC, CPC-E/M


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## dmaec (Aug 11, 2008)

thanks FTessaBartels - I'd agree I can get my HPI and ROS a bit more detailed - but how do you get a detailed exam?  What are you marking for that?
It seems my exam component is what's lacking, and I'm having difficulty pulling a detailed with only 2-4 systems... Const/neck/Eyes/ENT

what am I missing!  
thanks!


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## dmaec (Aug 11, 2008)

ohh..and I totally missed the "quality" stabbing pain... *sighs*...  correct on all 3 PFSH - (but even 2 gives me the complete).   I put the negatives under the ROS also, but still that's just equals a Detailed History - EXP Exam and MOD MDM - which is still a 99202 new patient.


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## dmaec (Aug 11, 2008)

Lisa Curtis said:


> For the HPI I have location (ear), quality (stabbing pain), timing (constant), duration (past few days); ROS I have constitutional (no fever) and ENT (no rhinorrhea or cough) - pertinent negatives; PFSH I have past hx (no chronic diseases/also that he has had ear inf twice in the past few years); family hx (diabetes not running in the family); social - smoker.
> 
> Exam I scored 4 organ systems = detailed because of the detailed nature of the ENT exam.



we must use different tools - my EXAM Component 2-4 systems including affected area is only equal to a Expanded Problem Focused.
hmmm.....


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## Lisa Bledsoe (Aug 11, 2008)

dmaec said:


> ohh..and I totally missed the "quality" stabbing pain... *sighs*...  correct on all 3 PFSH - (but even 2 gives me the complete).   I put the negatives under the ROS also, but still that's just equals a Detailed History - EXP Exam and MOD MDM - which is still a 99202 new patient.



Remember that 95 guidelines allow for 2-7 systems for EPF and Detailed.  I went detailed because of the detailed nature of the ENT exam...following 95 guidelines.


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## FTessaBartels (Aug 11, 2008)

*1995 guidelines*

Yes, I also was using 1995 guidelines for this one. 

GREAT question/ scenario, Donna!

F Tessa Bartels, CPC, CPC-E/M


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## dmaec (Aug 11, 2008)

of note ladies - I did let it go as the 99203 (but I didn't agree with it) ...however, *now* I'm seeing a different side.... and thank you both! 

we don't use the 95 Exam 2-7 (EPF/Detailed) score sheet - All the forms we have are the EXAM:
PF=1   
EPF=2-4
DET=5-7
COMP= 8 or more systems - but perhaps we'll change that now.

thanks again, I see what I missed now...


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## Lisa Bledsoe (Aug 11, 2008)

*95 guidelines*

Donna - I do know that there is some controversy over the guidelines you mentioned: 
EXAM:
PF=1 
EPF=2-4
DET=5-7
COMP= 8 or more systems
Because the actual guidelines state 2-7 for either EPF or Detailed.  I know other coders who do it the way your tool suggests, but I don't think that follows the guidelines the way they are intended...
Just my thoughts


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## daniel (Aug 11, 2008)

Great question posed.

I got a 99203, but on a side note you might want to go back to the physician and see how much time was spent directing the patient on quiting smoking.If it was 3 to 10min or 10min and above. You could squeeze in one of the CPT codes from the smoking cessation series. Just be sure to get him or her to document it in the note. Because looking at the physicians plan, he prescribed a prescription of chantix if I interpreted this note correctly.

So I would come up with something like this, for this encounter.

99203.25-462, 478.19

99406 3 to 10min- 305.1

     or 
99407 10min and above-305.1

Respectfull
Daniel
CPC


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## dmaec (Aug 12, 2008)

very good point daniel!  That thought hadn't even crossed my mind!  I'm doing a bit more research on my "tools".  

here I *thought* I knew what this documentation supported LOL... turns out Lisa, Tessa and now you have opened up a whole new way of looking at it for me!

Thanks so much for your opinion on this!


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## dmaec (Aug 12, 2008)

Hi Lisa, Tessa & Daniel -
thanks again for your comments on this documentation, it's been very helpful!
I just reviewed the "new" info and forms I have as far as E/M audit tools and, my newest E/M review form uses the EXAM EPF as 2-4 also (as did my other ones)  This last tool came from the 3rd Annual Coding and Billing Reimbursement Seminar this past May 2008! (put on by MMA)
It's the tool I've used since I started coding, it is the "95" guidelines (not the 97).  It's what I'm most comfortable and confident in using.  However, by using it - I can't get this note to a level 3 new patient.
At my previous job, another coder and I were looking at E/M auditing materials, we did find the type you guys are using, but we just couldn't quite figure out how to determine EPF or Detailed exam, using the 2-7 under both.  That's the area I'm going to be doing a bit more research in; what exactly makes it more detailed, how do you determine if a 2 system check (or however many) is detailed or expanded...  

thanks a lot for your input!


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## Lisa Bledsoe (Aug 12, 2008)

Donna - check out this link for some info on 95 guidelines and the difference between EPF and detailed.  I subscribe to this newsletter and it is often very helpful!
http://www.magnusconfidential.citymax.com/newsletters/newsletter/2248756/41535.htm


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## racheleporterwilliams (Aug 12, 2008)

Since this patient is new, I came up with 99203
det hpi-quality/duration/timing/mod factor/hx of multivitamins & sinus prob/constitutional/ent/cardio/resp/gu/all/endo/soc hx smoking, 
det exam-3 vitals/appearance/external auditory/oropharynx/nasal mucosa/neck/no lymphadenopathy/head autromatic/neck rom/A-O x3, 
mod complexity-new prob no work up/rx drug mgmt




dmaec said:


> Below is an E/M visit that I had to audit and score out.  If anyone has the time to score this out and let me know what they come up with (and how) I'd sure appreciate it. It is the exact note I reviewed to determine my level.  This documentation has become the hot topic around here as far as what level it is, and why.  I'll be bringing this note and my scoring E/M sheet to an E/M training class on August 28th.  It will be interesting to see what they think too!  Thanks for any input you have! I realize you'll probably have a few questions right off the bat, but please (that's part of my point), just work with what is written below.  THANKS TONS!
> SUBJECTIVE:  Patient comes today with complaints of stabbing right ear pain and some sinus pain and pressure. He feels that this ear pain is constant over the past few days. He complains that he has had an ear infection two times for the past few years. He has tried over the counter Excedrin for the pain and he does get some relief from this. In the past for his sinuses he has tried nasal saline spray, has not done this on any consistent basis. He has had no fever, rhinorrhea or cough. He has had these symptoms on and off for the past month but worse in the last few days. He reports that he is normally healthy. No chronic diseases such as diabetes, heart, lung or kidney problems. Diabetes does run in his family and 20 years ago he passed out from hypoglycemia so he does make it a point to eat small frequent meals so this does not happen again. He has not had a routine physical in 3-5 years.
> 
> Routine medications: Multivitamin.
> ...


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## dmaec (Aug 12, 2008)

Lisa Curtis said:


> Donna - check out this link for some info on 95 guidelines and the difference between EPF and detailed.  I subscribe to this newsletter and it is often very helpful!
> http://www.magnusconfidential.citymax.com/newsletters/newsletter/2248756/41535.htm



Lisa, thanks very MUCH for the link! great info!


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