# Need help is this a 99214



## dpumford (Apr 20, 2011)

HI! I am hoping someone can explain to me how this meets a 99214..It is an E & M example I was doing to educate myself and I need HELP!

CC: Chestpain
HPI:  58 yr old femal with intermittent, sharp chest pain over two weeks.  Episodes last 10 min at a time.  Pain occurs at rest.

PH: Non-smoker, no family history of Cardiovascular problems.

ROS:  No shortness of breath,  No reflux

Exam:  Vitals:  BP 120/80, P 65
           Lungs: clear to auscultation
           CV:      normal

A/P Chest pain.  ECG and stress test ordered.  Follow up scheduled.

This is  an example of a 99214 and I am hoping someone can give me some insite.  The Hpi and Ros is fine its the rest  

Thanks in Advance


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## LLovett (Apr 21, 2011)

*That is not a good or even realistic example*

I am guessing they are basing it on Hx and MDM. 

History is detailed, exam is problem focused 97 and expanded problem focused 95, MDM is really crappy but I guess they are saying this is a new problem with work up (4 dx points), 1 data point for ordering testing, and moderate risk for an undiagnosed new problem which gives you moderate risk.

Hope that helps,

Laura, CPC, CPMA, CEMC


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## btadlock1 (Apr 21, 2011)

I agree with Laura on the exam and MDM, but I'm still not sure that this is quite a 99214. The BP and pulse are not remarkable, and the CV exam notes "normal", which by CMS Documentation guidelines, is insufficient. There should never be a notation of "normal" without further elaboration, from the system chiefly responsible for the presenting problem. (That would be considered a 'pertinent negative' finding.) 

That coupled with no prescription, advice, or tentative plan of care, gives the impression that the provider doesn't view the patient's condition as 'critical' or 'acute'; the tests could have been ordered, just to rule out any cardiac anomolies. Without at least a 50/50 chance of the condition worsening before the next visit being conveyed in the record, I'd be hesitant to make this a 99214, even though it _technically_ meets the CPT requirements. I tend to be more conservative, though.


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## dpumford (Apr 22, 2011)

Thank you ladies!  This gives me more insite


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## colorectal surgeon (Apr 24, 2011)

Someone told me once that in order for vitals to be considered a 'system' one had to document 3 vital signs. If so then this wouldn't qualify as 99214. Any comments?


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## btadlock1 (Apr 25, 2011)

colorectal surgeon said:


> Someone told me once that in order for vitals to be considered a 'system' one had to document 3 vital signs. If so then this wouldn't qualify as 99214. Any comments?



I believe that's only 1997 guidelines, but I could be wrong.


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## LLovett (Apr 25, 2011)

3 or more vitals counts as 1 bullet for constitutional under 97 guidelines. There are no bullets in 95 so as long as 1 thing is listed related to that organ system or body area then you get credit for examining that system/area.

In this example the 99214 is based on Hx and MDM so it doesn't matter what level of exam you have.

Laura, CPC ,CPMA, CEMC


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