# 99213 vs. 99214 Thoughts?



## fredcpc (Dec 22, 2010)

Can you look at this Encounter, it is baffling me. Here it is:

Pain location: Headache
Pain Scale: 1
Follow up on Headache and HTN.

Allergies: Adhesive, Metformin, Ace Inhibitors

He tried increasing metoproiol to 150mg bid with increase in HA noted. He called me by phone and I advised tapering metroproil down to current dosage of 50mg bid, which he has noted has helpd his HA to about 30 percent of prior severity. He said at it worst the HA feels like "a whack on the head." He does note that metropriol was also helpful in PVC Tx. 

His glycemic index is poor. Fasting glucose is is around 140, pm glucose is 120-140.

Meds: Cozaar, Actos, Metroproli

Phys Exam:
GEn: Obese man in no distress
HEENT: Temporal arteries nontender; Oropharnyx is benign.
Lungs: Clear to asculation and percussion.

IMpression: 1) Headache -- He is improved with with reduction of metroilol. Will continue to taper metroprioil by 50% every 10 days. Reacessment in a month. 

2) HTN -- See recommendations to taper off metroprioil. Reexam in a month.

Initially, I got 99214. Det, exp, Moderate. What do you think?


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## ollielooya (Dec 22, 2010)

These are my thoughts and hoping the veterans will comment.  I've worked it from the MDM backwards and have come up with a level 4 for this established patient..  Briefly you have MODERATE MDM due to the presenting problems of HA and HTN along with medication management.  Not sure if the EXAM would be PF or EXP because I only count 5 items.  Are you using 95 or 97 guidelines?  (Doesn't really matter since the other two components will substantiate  the level.)   HPI  contains the following elements:  location, quality, severity and modifying factors which qualifies for an extended HPI + 2 bullets for ROS and PMH = DETAILED.  Since  you've met two out of 3 required components for an established patient, I would assign Level Four.    Again, hoping others with credentials in this field will comment (and correct my thinking) as I have a keen interest in this area.  ---Suzanne E. Byrum, CPC


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## msrd_081002 (Dec 22, 2010)

*E/m-99214*

I agree with you. I'll append *99214* (for the specified documentation).

Thanks


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## btadlock1 (Dec 22, 2010)

This is why I don't like the wishy-washy system of using both sets of guidelines - we can opt to the more generous one when it suits us? I prefer that boundaries be clearly laid out - there's less room for mis-interpretation. I wouldn't have assigned the exam as EPF, no matter how awesome it ranked on the "Some carriers will accept 2-9 systems" definition for an EPF exam. I mean, look at what he actually _did _during the exam - seriously. Get a mental image going. He walks in the room, and makes an observation about the man's weight and the fact that he's obviously not having an emergency at the moment (both of which are easily accomplished with a casual glance). He listens to the guy's chest, which is virtually routine, no matter why you see the doctor; and then gives the patient's face and neck a little pat-down. Exam? Check! 
He may have been more thorough than that, but without documenting it, we'll never really know. The notes indicate an extremely brief, *definitely *problem-focused physical exam - the more stringent guideline should be applied, in my opinion.


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## fredcpc (Dec 22, 2010)

*99213 vs. 99214*

I came up with a 99214, but felt strange about it. 1995 guidelines were used on this case, but it was audit of a doc that choose a 99212. My first impression was to advise a 99213, and if we work in Medical necessity, it will be a 99213; which is the over-riding factor. Good counters and many experienced coders would still get a 99214. THe only thing that is left is medical necessity. 

It would be a 99214 no matter which set of guidelines were used. Food for thought.


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## btadlock1 (Dec 22, 2010)

Yes it would, since the patient's established. You've got a solid 99214, so don't sweat it.


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## fredcpc (Dec 22, 2010)

*Another Case: OV with EKG and X-ray*

Here is another scenario that is cause for thought and feedback....

Medicare patient
Sex; female
Pain Scale: 4
Pain location: Chest
Surg Hx: Hysterectomy

Allergies: Epinephrine, Furosemide, Tramadol

Here for eval of chest pain. Hx of Coronary artery disease, RCA stenting in 2004. In the past week, she has had an onset of chest pain that began with a few twinges of pain lasting for a few seconds, underlying the left side. In the past few days this has increased to to involve sternal area as well. The pain does not feel like a pulling muscle. She took some Devocet with improvement of symptoms.

She denies cough and dyspnea. There is no dysphagia or odynophagia. The pains are worse when lying on left side. No leg swelling. No calf pain or hemopytosis. She denies fever, chills, and PND.

Current Meds: Cozaar, Plavix, and Darvocet

Family Hx: Son and brother with MI; Mother with HTN.

Social: She is a non-smoker.

Phys Exam:
General -- overweight, pleasant in no distress
Neck: JVP not elevated
Lungs: Clear to asculation and percussion. Respirations are unlabored. No chest wall tenderness.
Cardiac: Rhythm is reg with normal S1 and S2 and 1/6 mid-systolic murmur at lower left sternal border. No radiation. JVP not elevated.
Abd: soft and nontender. No mass. No aortic bruit.
Extrem: Without edema. No calf tenderness.
Chest: X-ray reviewed personally by shows normal heart size and clear lung fields. No change from 2005. EKG shows show normal sinus rhythm. rate 56, with no repolarization change. Toponin I is .03.

IMPRESSION: Chest Pain. Suspect noncardiac pain, prob chest wall. Advised continued use of Darvocet. She was instructed in nitroglycerin use as trial. PHone follow in 48 hours. Possible Myoview test in future.

My thoughts and questions: Can we code a EKG, for example, 93010? How about an Xray code? We have a partial EKG strip that has the doctor handwriting stating, "Normal EKG" and the doctor also signs the EKG strip machine strip and his interpretation. I feel that this is not enough to code a 93010 because we don't have the doc saying, "Interpreted by me" or anything like it. Bottomline: I would lean towards just a 99203 with 786.50.


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## AB87 (Dec 22, 2010)

can someone give me the break down on how this is a 99214??? im looking and all i can get is a 99213

thanks!


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## fredcpc (Dec 22, 2010)

*99213 vs. 99214*

The breakdown is Detailed, Exp, and Moderate MDM. Why? It has 4 HPI, 2 ROS, which equals a Det. The Exam is very slight, so it makes a expanded exam. And, it is moderate MDM because the Doc change his meds and will further alter his prescription management. This is using 1995 Guidelines. Any thoughts?

I had to look twice before I came up with a 99214. Strange case.


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## LLovett (Dec 23, 2010)

Hold up. On the first case you have F/U for Headache and HTN, so these are both established problems and they are both stable so that is only 1 dx point each. Even with Moderate risk, you are stuck at low MDM.

What are you counting for ROS? 

This would be a 99213 if I was auditing it.

On the second, I would be ok with coding the review of the EKG but why are you not going to code the global code, who did the EKG? If it was done somewhere else it has probably already been interpreted, same as the x-ray, and therefore not billable by your provider, these would just be part of the MDM data points for your E/M.

Just my take on it,

Laura, CPC, CPMA, CEMC


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## cheermom68 (Dec 23, 2010)

*99213*

Laura,
I am so glad that you chimed in on the first scenario.  I couldn't figure out where they were getting the moderate MDM for the life of me.  Thought my brain was already on vacation. I agree with the 99213.

LeeAnn


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## fredcpc (Dec 23, 2010)

*99213 vs. 99214*

We have a detailed hx. ROS is glycemic control, Allergies. So Hx is Detailed. I think we were seeing the consult and the med management and going for a moderate MDM. 

On the EKG, do I need to have the physician say "interpreted by me?" or use the word interpreted in his notes? 

I have a partial EKG which I don't if it is a 12 or 3 lead? This strip is only as wide as a notebook piece of paper. It is does say Internal Medicine at the top of the sheet; the doc wrote "EKG Normal" on the partial strip and signed it. 

I do have sufficient input from on the Chest part of the Exam, that could be an interpretation.

Here is the question. I don't have a full strip. The doctor did not say "Interpreted by" somewhere in the notes or on the strip; and I don't know if it is 12 or 3 lead.


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## fredcpc (Dec 23, 2010)

*99213 vs. 99214*

Thank you all the wonderful and experienced input. I appreciate you patience and time too. Happy Holidays!!


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## ollielooya (Dec 23, 2010)

Laura, I took anothe look at this first case again and noticed the two established problems in the MDM, and of course that = low.  So that altogether DOES plunge the level to Three.  Still a student at this, love it, but obviously stand corrected on my error.  Thanks for pointing that out. *99213 * ---Suzanne


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