# E&M coding with Fever



## dappy (Oct 23, 2015)

What E&M code would you use for this note? pt is a 9yr old female

 Chief Complaint(s): 
  Severe cold 

  HPI:   
     ENT
         Pt presents, accompanied by mom, 2 day h/o increased fatigue, low grade fever -Tmax 99, sore throat, decreased appetite, cough- non productive. Mom reports that a lot of children are sick in her class. Mom has not given her any medication. Mom would like pt to r/o for strep throat. 
  Current Medication: 
     Not-Taking/PRN
  Cortisporin Otic 1%-0.35%-10000 units/mL otic solution 4 gtt 4 times a day 

  Medication List reviewed and reconciled with the patient 

  Medical History: 
  Repeat C-section 38+4 weeks 

  Birth weight 7-2; d/c weight 6-8.7 

  Mom's blood type A+; mild jaundice 

  RAD--home nebulizer 

  RSV bronchiolitis--1-09 

  heart murmur--w/u by cardiology at birth 

  Allergic rhinitis--cats 

  Allergies/Intolerance: 
  Cat - itchy eyes 

  Gyn History: 
  OB History: 
  Surgical History: 
  Appendectomy 09/2014 

  Hospitalization: 
  Denies Past Hospitalization 

  Family History: 
  Father: alive, Allergic to Amoxil 
  Mother: alive, Allergic to PCN 
  Siblings: alive, Sister allergic to Amox 
  Paternal Grand Father: deceased 40 yrs, Car acident--hit and run; very little family hx 
  Paternal Grand Mother: alive, Depression, Bipolar, Alcoholism 
  Maternal Grand Father: alive, unknown--never married to mom--no contact 
  Maternal Grand Mother: alive, Alcoholic, doesn 
  1 brother(s) , 1 sister(s) - healthy.  
  Social History: 
      no Other Tobacco use. 
      no Secondhand Smoke. 
      PCP Verification: done Do you consider Avance Care as your PCP?  Yes.  
      Last CPE/Well-Child: done When?  Date 09/2015.  
      Occupation: student. 
      no Abused. 
      Safe at home: yes. 
      Home smoke detector use: yes. 
  ROS:
     CONSTITUTIONAL
        Sick Contacts yes.  Fever yes.  Chills yes.  
     HEENT
        no Runny Nose.  no Ear Pain.  Sore Throat yes.  Cough yes.  no Post-nasal Drip.  
     RESPIRATORY
        no Nasal Congestion.  no Shortness of Breath.  
     CARDIOVASCULAR
        no Irregular Heart Beat.  no Chest Pain.  
     GASTROINTESTINAL
        no Nausea/Vomiting.  no Constipation/Diarrhea.  no Abdominal Pain.  
     SKIN
        no Rash.  


Objective: 
  Vitals: 
       Wt 72.2, Wt Change 4.2 lb, Ht 54, BMI 17.41, Temp(F) 100.2, HR 98, RR 18, BP(Systolic/Diastolic) 102/96 
  Past Results: 
  Examination:   
     ENT
        Eyes: Bilateral conjunctiva without erythema or drainage.  
Ears: No discharge, bilaterally tympanic membranes with good light reflex and pearly color.  
Mouth: dry mucus membranes.  
Throat: mild erythma, no exudates; , tonsils 2+ size.  
Neck : enlarged nontender lymph nodes.  
     General Examination
        General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.  
Heart: Regular rate and rhythm, no murmurs.  
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.  
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.  
  Physical Examination:


Assessment: 
  Assessment:
  Acute pharyngitis, unspecified - J02.9 (Primary) 



Plan: 
  Treatment: 
    Acute pharyngitis, unspecified 
         Lab:Rapid Strep (IH) (CPT 87880)  Negative                 Result neg   
                Control pos   
         Lab:Culture, Throat (DP 10) (CPT 87070) 
         Notes: Rapid strep negative. Will send for cx. Will notify mom of results. Mom to alterante children's tylenol and children's motrin every 3-4 hrs for fever and pain. Mom to push fluids to maintain hydration. Mom to call with any questions or concerns. Mom voiced understanding to plan. 
  Procedures: 
  Immunizations: 
  Therapeutic Injections: 
  Diagnostic Imaging: 
  Lab Reports: 
  Preventive Medicine:

  Next Appointment: 
  as scheduled 


Thank you


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## janicer (Oct 23, 2015)

*99203*

99203


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## consultingbykristin (Oct 23, 2015)

I say 99202.  MDM is low and while there's a lot of documentation, was it all truly necessary for this visit?  Documentation volume should not be considered when assigning a code.  There's a lot of family history data that's irrelevant.  Also some of the HPI is the same as what is listed in ROS.  We can't double dip.  He said patient has a cough and fever that's HPI.  For ROS, I didn't count the bullets if it was the same detail as he noted in HPI.


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## CodingKing (Oct 24, 2015)

I'd have a hard time assigning anything higher than a level 2 for a case where the diagnosis is pretty much known before the patient walks in the door. If there was an OTC rapid strep test I don't even think they would have even come in the office. The only family history that would even be relevant to the case would be allergies to antibiotics otherwise it's just fluff.


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## dappy (Oct 26, 2015)

Thank you so much for all the input.  That was my impression also.


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## thomas7331 (Oct 27, 2015)

I share the concern about the fact that the medical necessity doesn't appear to support the level of detail in the documentation, but would just urge caution in this area.  I'd point out that the documentation requirements of 99203 (which is not a high-level code to start with) are met here even if you take out the more obviously 'irrelevant' information.  To further disqualify history or exam elements based on medical necessity requires some knowledge of clinical practice and is something that's best pursued with the input and participation of the provider.  There are often details in the patient's history that require a more extensive provider work than what might appear to the untrained observer.


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## kimgiz (Oct 27, 2015)

I agree with Tom, 99203.


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## dappy (Oct 28, 2015)

My Doctor insists it is a lv 4 due to the pt having a FEVER.  The doctor considers it an 'Acute illness with systemic symptoms'.    

Thanks for all the good comments.


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