Internal Medicine Coding Alert

Question: Even though pneumonia is a serious diagnosis, I think a chart supports only 99212. Chart shows:

Michigan Subscriber

Answer: No, the note describes 99212. You have a problem-focused exam and straightforward medical decision making (MDM). Depending on how you count the phrase "no coughing, SOB," you could have a problemfocused history or an expanded problem focused history. Either type ultimately does not change the E/M selection. Although the case involves pneumonia, the condition is resolving and does not require as much history, exam-ination, and MDM. Treatment for the same condition may involve different levels of care, depending on the work involved in the encounter -- and where in the treatment phase (initial work-up, worsening, resolving, etc.) the patient is. Let's break down the documentation's components:

You could count "no coughing" and "no shortness of breath (SOB)" as associated signs and symptoms under history of present illness (HPI). Some auditors mightinstead give credit for reviewing the respiratory system, giving the internist a problem-pertinent review of systems (ROS) (1 system: respiratory -- no coughing, shortness of breath). If you instead put the phrase under HPI, you have an extended HPI) (4 elements: duration --

since 12/08; severity -- minimal; location -- right lower lobe; associated signs and symptoms -- no coughing, no SOB). You have no past medical, family, and social history (PFSH). Using the phrase under ROS, rather than HPI, gives you an expanded problem-focused history (extended HPI, problem-pertinent ROS, and no PFSH).

You could argue that the history is problem-focused (extended HPI, no ROS, no PFSH). The documentation supports a problem-focused exam: 1 organ system examined (respiratory).

You have straightforward medical decision making (MDM), which Medicare considers the overarching driver for code selection. A recheck of a known problem that's resolving gives you one point under Number of Diagnoses or Treatment Options (ND/TO). You have one point for amount and/or complexity of data to be reviewed for review of chest x-ray. The chest x-ray order gives you a minimal risk level. 1 ND/TO + 1 data + minimal risk = straightforward MDM.