Wiki 99213 vs 99214

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We are having a discussion where I work in regards to 99213 vs 99214. If a patient comes in for a sore throat with a negative strep test would this meet a level 4? The provider documents a detailed history, detailed exam and the decision-making meets moderate due to a new problem with a prescription.
The documentation supports a 99214 but does the medical necessity and the presenting problem??

Thanks for all of your help!
 
Yes, it clearly supports a 99214.

Sore throat could be any number of things so how can you say what the medical necessity just based on a chief complaint of sore throat and a negative strep test? A patient with Mono will test negative for strep and generally complains of a sore throat, they also run the risk of their spleen rupturing. Would you consider them lower risk?

In this case it is a straight 4, many times you won't have that detailed exam on these visits but they are still 4s.

Laura, CPC, CEMC
 
I don't see a Moderate Complexity. I come up with Low. You also need to way out the necessity for performing a detailed exam. What systems were examed?
 
New problem no additional work up 3 points, 1 data point, Rx management moderate risk. You drop data and you have Moderate MDM.

Laura, CPC, CEMC
 
I'd like to see the entire note

The patient has a negative strep test, but gets a prescription ... for what?

One might argue that a "sore throat" is a "self-limited or minor" problem (1 pt)vs a "new problem without workup" (3 pt)

I think you might be able to argue both cases. It would all depend on the documentation. In our clinics, if the documentation is there we (the coders) do not argue medical necessity. Then again, we're not using an EMR, where it is quite easy to over document.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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Medical necessity for exam

jwersland said:
We are having a discussion where I work in regards to 99213 vs 99214. If a patient comes in for a sore throat with a negative strep test would this meet a level 4? The provider documents a detailed history, detailed exam and the decision-making meets moderate due to a new problem with a prescription.
The documentation supports a 99214 but does the medical necessity and the presenting problem??

Thanks for all of your help!
Click to expand...

Does a sore throat meet medical necessity for a detailed exam? I highly doubt it. The highest I would be inclined to give is 99213.
 
The exam is as follows: Keep in mind we use the 95 guidelines 5-7 systems examined meets detailed
PHYSICAL EXAM:
GENERAL: She is a pleasant, alert. She does not appear in any acute or
severe distress.
VITAL SIGNS: Include a blood pressure of 127/79. Heart rate of 87.
Respiratory rate of 16. Temp 98.4. O2 sat on room air of 99%.
HEENT: Reveals her TMs to be normal. The oropharynx is without lesions.

NECK: Supple without masses, bruits, or thyromegaly.
CHEST: Clear.
HEART: In a regular rate and rhythm with a normal S1 and S2. No S3, S4,
no murmur.
ABDOMEN: Soft and nontender. No masses, guarding, rebound, or rigidity.
EXTREMITIES: Without clubbing, cyanosis, or edema.
 
1995 guidelines

We use 1995 guidelines, which are, admittedly, vague.

IN actuality for a detailed exam the 1995 guidelines state: an EXTENDED exam of of the affected body area or organ system AND other organ systems.

So I would not count this exam as detailed. The only mention of the throat is "oropharynx is without lesions." I'd want to see more information regarding the examination of the throat, nose, ears, chest. Some DETAIL about the physician's exam of the affected body area or system.

But even with that ... I go back to ... why give a Rx? There doesn't appear to be anything wrong. No fever. No chest congestion. No otitis. No runny nose.

As I said before, our coders do NOT second guess the physicians on medical necessity, but I know that some auditors DO look at this. And this documentation just doesn't seem to warrant a 99214.

You must be wondering about this as well, or you would not have posted the question.

F Tessa Bartels, CPC, CEMC
 
Thank you so much!!! I have went back and forth on this with our senior auditors and pointed out that there is not an EXTENDED exam of of the affected body area or organ system AND other organ systems. They say since there are 5-7 systems examined that it is detailed. This just does not seem right to me!! In regards to the rx I ask the same question and a lot of times it is at the patients request or a "safety" script. I really appreciate all of the responses I am getting.
 
Detailed exam?

The "detailed exam" should be a more in-depth exam of the affected organ system or body part and exam of related organ systems or body parts. There is also the issue that there are no DG's that state 5-7 = detailed. Hence the vagueness of 95.
 
I agree with Tessa and Lisa...

When a patient complains of a sore throat, the automatic response (almost always) is to perform a strep test. If the strep test is negative and there's no other alarming issues going on, this could be viewed as a self limited/minor problem. As for the RX, some of my physicians prescribe Magic Mouthwash for comfort (ease oral and esophageal pain). Since I'm not clinical, I try not to determine medical necessity unless it's boldly, starring me in the face. With that being said...I know that some of our physicians could argue a detailed exam, using 95. Again...it depends on documentation and medical necessity...
 
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