Internal Medicine Coding Alert

Question: The risk management table for E/M services lists prescription drug management as moderate risk. Does this mean I can code 99214 when an encounter requires an antibiotic?

Colorado Subscriber

Answer: Prescribing an antibiotic does not automatically mean you should code a level-four E/M service (99214). The table, which CMS includes in the E/M Documentation Guidelines, means that the risk associated with a patient who requires antibiotic treatment may be at the moderate level or near it.

Key: Medical necessity must guide the elements that the internist performs and documents. For instance, the following note supports 99214:

• CC: Fever and vomiting

• HPI: Congestion and wet cough for four days, Temp to 103 for two days, Vomiting 2x today; Fatigue with poor eating, sleeping

• PFSx: Hx otitis x 3 in past 6 mos; Fhs others ill resp illness; Shx: Smoker

• ROS: GI -- vomiting; neuro -- irritable but responsive

• PE: temp 102.5, RR 24, Wt 168 lbs;

skin flushed, turgor good; eyes jaundiced; TM's erythematous, bulging; pharynx mod erythema; neck supple; chest clear to auscultation; heart reg rhythm without murmur; abdomen soft, without masses, tenderness

• Impression: Otitis media, recurrent; vomiting; fever

• Rx: Amoxicillin, Tylenol, clear fluids with diet advanced as tolerated; discussed in detail with patient

• F/U ear recheck in 2 to 3 weeks.

The chart includes these 99214 qualifying elements:

• five history of present illness (HPI)

• three past, family and social history (PFSH)

• two review of systems (ROS).

• seven body areas/organ systems assessed in physical examination (PE).

For the diagnoses, you would code acute otitis media (382.00), vomiting (such as 787.03, Vomiting alone) and fever (780.6). OM with systemic symptoms noted supports the medical necessity of 99214 for this visit.