Ob-Gyn Coding Alert

Question:  My ob-gyn documented the following:

Established patient

CC: Vaginal Discharge

HPI: Extended 4 day history of a constant vaginal discharge associated with odor. Nothing makes it better.

Past Medical History Reviewed

ROS 3+ systems reviewed

Exam: Full pelvic exam but no further exam performed. KOH/Wet prep confirms bacterial vaginosis.

Medical Decision Making:

1) New problem diagnosed with no further workup needed

2) New RX Flagyl given to patient

How should I code this? Is it a level 3 or level 4 established patient visit?

Arkansas Subscriber

Answer:  For this problem, you have no medical need for it to be above a 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family). Just because you can perform a detailed history or exam does not mean it was medically indicated, and the presenting problem is the key to determining the level of history and/or exam warranted. 

You have a chief complaint, extended HPI, 2-9 Review of Systems, and PMHx. The exam is problem focused. For the MDM, you have 1 point for data, new problem no additional work up (3 pts), and the ob-gyn prescribed Meds (Rx drug management). So this is moderate risk.

In this case, you should consider the exam as the deciding factor, not the history because the presenting problem without more information does not warrant a detailed history for an established patient. If the documentation had instead stated that this patient had several infections during the year, and had not been seen by this provider in over a year, a case might have been made to move up to a level 4 service.