# does this qualify for level 4 office visit



## mstyus (Mar 4, 2010)

Hi Coders,
I am stumped on this example ,So please can someone help with references
An established office patient with hypertension, diabetes and a history of dyslipidemia 
CC: Follow-up hypertension and diabetes

Interval History: The patient's hypertension has been well controlled on current medications. Diabetes is stable as well, with no significant hyperglycemia or episodes of symptomatic hypoglycemia. Dyslipidemia remains well controlled on statin therapy.

Medications

Lisinopril 20 mg po qd
Atorvastatin 10 mg po qd
Glyburide 10 mg po bid

ROS
General- Negative for fatigue, weight loss, anorexia
Cardiovascular- Negative for chest pain, orthopnea or PND
Neurologic- Negative for paresthesias

Pertinent PFSH is remarkable for mild OA which has been quiescent

Physical Exam
General: NAD, conversant
Vitals: 120/80, 65, 98.6
HEENT: No JVD or carotid bruits
Lungs: CTA
CV: RRR
Extremities: NO peripheral edema

Labs: BUN 12, creainine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77

Assessment
1.Well controlled Type 2 NIRDM
2.Well controlled hypertension
3.Stable dyslipidemia

Plan
4.Continue current medications unchanged
5.Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
6.Check LFTs at next visit as well due to ongoing statin therapy
7.Continue lifestyle modifications and exercise for weight loss
8.Return visit in four months


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## FTessaBartels (Mar 4, 2010)

*What do you think and why?*

Well, I can give you MY assessment, but I think it would be helpful to know what *you* are thinking and why (yes, it does / no it doesn't because of ....)

For a 99214 you need 2 out of the following 3 key elements:
Detailed history
Detailed exam
Moderate MDM

I'll start by telling you that by 1997 guidelines you have a Detailed History (status of 3 chronic conditions used for HPI).

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## aguelfi (Mar 12, 2010)

I come up with a detailed history, EPF exam and Moderate decision using the 1997 guidelines.  99214


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## mjewett (Mar 12, 2010)

Using the 1995 DG 
I came up with:
Detailed History
EPF exam
Moderate MDM

equals 99214


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## mjewett (Mar 12, 2010)

I just want to clarify I didn't use the 1997 DG's b/c I did not credit the three chronic conditions as part of the HPI. If you do credit three chronic conditions then you must use the 1997 DG's.


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## FTessaBartels (Mar 12, 2010)

*Carrier specific*



mjewett said:


> I just want to clarify I didn't use the 1997 DG's b/c I did not credit the three chronic conditions as part of the HPI. If you do credit three chronic conditions then you must use the 1997 DG's.



At a conference on E/M coding I attended a few years back it was pointed out that some carriers DO allow you to mix the "status of 3 chronic" conditions with the 1995 exam guidelines.  (It's *not* my carrier, so I didn't pay closer attention.)

F Tessa Bartels, CPC, CEMC


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## jwestfall (Mar 15, 2010)

Yes, this qualifies for a level 4 est. patient.

Detailed history and moderate MDM = 99214


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