Part B Insider (Multispecialty) Coding Alert

Review this documentation and determine how you’d code it before you read the solution.

When you see an extremely thorough initial inpatient E/M note, your first instinct may be to agree with the physician’s high-level code for her extensive work. But if even one element of a particular code isn’t met, you won’t be able to report it—even if the rest of the documentation is pristine.

See if you can spot the problems with this physician’s initial inpatient care note.

Code reported: 99223

Chief complaint: Retrosternal left-sided chest pain, which started this morning.

HPI: This 72-year-old female has a history of hypertension, type 2 diabetes and nonischemic cardiomyopathy. She has a history of paroxysmal atrial fibrillation, gastroesophageal reflux disease, gastric polyp, irritable bowel syndrome, diverticulosis, glaucoma and recurrent bronchitis. She had a hemmorhoidectomy previously. Last angiogram was 56 days ago and that did not show any obstructive coronary artery disease. She woke this morning with sharp retrosternal chest pain, with the pain at seven out of ten, radiating to the left shoulder. There was associated shortness of breath and nausea but no dizziness. There are no aggravating factors at this time. 

The patient’s current medication list is attached hereto. She has no allergies and does not smoke, drink alcohol or use recreational drugs. She lives with her husband. 

The patient’s mother died of breast cancer and her father died of lung cancer. Her four children are all alive and healthy. She has no siblings.

ROS: Constitutional: Negative for fever, chills, fatigue

Cardiovascular: Negative for orthopnea, positive for pain over left side

Gastrointestinal: Negative for nausea, vomiting, diarrhea, pain

Musculoskeletal: Negative for pain in joints. Gait is normal.

Integumentary: Negative for itching, hives or flushing.

All other systems have been reviewed in detail and they are otherwise negative besides what has been discussed above already.

PHYSICAL EXAM:

General: Patient is pleasant and well-groomed, and is in no significant distress at this time

Vital signs: Blood pressure 140/75, pulse 79, respiratory rate 21. She is afebrile. Saturations 99% on room air.

HEENT: She is anticteric. Extraocular muscles move normally. There is no oropharyngeal inflammation.

Neck: No elevation of jugular venous pulse, carotid bruit or thyromegaly

Chest: Clear to auscultation bilaterally without rhonchi, wheeze or crackles

Heart: First and second heart sounds are normal without murmurs. Chest pain is reproducible with moderate palpation, but not with movement of her arms

Abdomen: Soft and nontender with no hepatosplenomegaly

Extremities: No clubbing, cyanosis or edema; peripheral pulses are present

Neurologic: Nonfocal

Skin: No skin lesions seen

Psychiatric: No overt psychiatric anomalies found

LABORATORY: EKG shows sinus tachycardia with left axis deviation with no significant abnormalities otherwise indicated. CBS normal. Hemoglobin 13.2. Coagulation screen, electrolytes and liver tests normal. Glucose 144. Alkaline phosphatase is 171. BNP 153.

Chest x-ray is negative, but heart is borderline enlarged.

ASSESSMENT:  Atypical chest pain which seems to be musculoskeletal in nature. She had a recent angiogram, which was negative for any significant obstructive coronary artery disease. 

PLAN: She is admitted to hospital. Continue home medications. If enzymes are negative in the morning, which we expect, we will discharge her. 

Can You Spot the Problem?

Although the history and physical exam portions of this note are comprehensive and therefore would normally support 99223, the medical decision-making is only moderate complexity, which limits the note to 99222. Because you must meet all three requirements to report a given level of initial hospital care E/M, you must report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals …Typically…are spent at the bedside and on the patient’s hospital floor or unit. ) for this service.

Time option: In the absence of an appropriate level of medical decision-making, the physician in this case would be able to code the visit based on time spent with the patient if that was documented. To qualify for 99223, which the doctor in this case reported, she would have to document 70 minutes spent at the bedside and on the patient’s hospital floor or unit, with at least 35 minutes of that spent counseling or coordinating care.