# E&M Levels in Jan "Healthcare Business Monthly"



## zoolug (Jan 2, 2014)

RE: "Cure What Ails Yor Physician Documentation" in AAPC's January "Healthcare Business Monthly".

Is it me, or is the author assessing too low on some of the key component levels on the 3 cases? In particular, below is part of Case No. 2....

Case No. 2

"Chief Complaint: Infection - EENT

History of Present Illness: A 56-year-old divorced gentleman is in for nasal congestion and cough he has had for almost two weeks. The cough interferes sometimes with sleep at night and during the daytime. He has tried cough syrup with little to no benefit. He mentioned that it could be related to his Lisinopril; although, he has been on that a long while and does not think it is due to that at this time. In the future, if it persists we might want to swtch to Loratadine, which was prescribed during a previous visit.

Allergies: No known allergy

Social History
Marital: Married, Children: 3
Tobacco use: former smoker. Notes: Quit in Jan 1996
Alcohol use: Drinks socially
Current Medications: Lisinopril

Review of Systems
Cardiovascular: No chest pain, palpitation. Respiratory: Cough, fairly non productive. No Fever.
...
Plan
-Congestion with cough: Wrote for guaifenesin with codeine 2-3 tsp hs or q 4 p.r.n. nighttime cough, 8 ox two refills and guaifenesin with DM 2-3 tsp 1 4-6 hr pr.rn daytime cough, 8 oz four refills. Benzonatate 200 mg q 8 her p.r.n. cough that can be added to the cough syrups, #50 with five refills. He is on BiPAP every night on a long-term basis. He does have some bronchospasm and we will temporarily, at least, give prednisone burst 10 mg tablets 4 a day for 2 days, 3 a day for 2 days, 2 a day for 2 days, 1 a day for 2 days and discontinue. For daytime congestions, pseudophedrine 120mg 12 hour preparation taken in morning. Should fade out by night. Can interfere with sleep if he takes later in the day or takes the 24 hour preparation by mistake.
- Lisinopril 10 mg at hs, which he is already unigh, can be continued
- Recheck planned in 6-8 weeks. He can let us know sooner if he has ay questions or problems on these new medications."

The author says the History is EPF. I see clearly a detailed history. 4+ HPI elements: location (nasal), assoc sx (congestion and cough), duration (almost two weeks), modifiying factors (tried cough syrup with little to no benefit). 2+ ROS systems: cardio, resp, general (no fever), plus ENT if you count what's in HPI. Social history (both under that heading and in HPI). So that is one of PFSH and smoking is clearly pertinent to cough.

The author says the MDM is low.
In the plan the provider prescribes several medications and reviews the exisiting prescription. That makes moderate risk, so add a new problem with no work-up planned and you get 3 problem points plus moderate risk equals moderate MDM. I  suppose you could argue low risk from acute uncomplicated illness of cough w/congestion, but it seems to me it is complicated by his existing respiratory issue implied by the BiPAP use.

I would appreciate any feedback.

Thanks,
Paul


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## LLovett (Jan 2, 2014)

*I agree with you, this was under coded*

I easily get Detailed history and Moderate MDM, depending on how you score the exam it could go different ways but in as an established patient in this case exam doesn't matter.

Case 1 is under as well. That is not a Problem Focused history, it is Expanded Problem Focused as is the exam, the MDM is Moderate.

I have seen some facilities set up their own internal guidelines that would force these types of services to be down coded similar to what the author has done here. If that is the case it should be stated that is what they have done. I personally disagree with facilities that do this but it is their risk to take.

I would like to see the author explain which elements they counted and why they ignored others. The leveling on cases 1 and 2 don't follow any published audit tools I have ever seen. 

Just my take on it,

Laura, CPC, CPMA, CEMC


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## astephens (Jan 2, 2014)

*E/M level*

I don't see the PE


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## zoolug (Jan 2, 2014)

*here is the PE*

Hi Angelica,

I left out the PE, because I did not disagree with the author on that part. She says the PE is EPF. I would argue Detailed by 1995 rules, but by 1997, there are definitely not 12 bullets. Here is the PE...

"Pupils are 2 mm and reactive. Ears, normal TMs and canals. Mouth, Normal mucosa and gingiva. Neck, no adenopathy; thryroid not enlarged. Lungs clear, symmetric to A&P. Hear regular, no murmur. Abdomen nontender, no hepatosplenomegaly."

-Paul


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## lorrpb (Jan 2, 2014)

I suggest that you share these concerns via a letter to the editor. This will give the author an opportunity to respond, because the discussion board is not monitored.


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## TraciTorres320 (Jan 6, 2014)

I'm in agreement that these cases were undercoded - very much under coded.

Traci Watts-Torres, CPC, CPMA, CEMC


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## mizdez (Jan 7, 2014)

*Desiree Straehla, CPC*

Thank  you for writing something.  I thought I was going crazy.  Undercoded!


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