Wiki 99213 vs. 99214

[tmorehart]

I have a question for those of you with more experience than myself.

If I have an established patient being seen for ear infection, sinus infection, pharangitis and the documentation levels out to a 99214 would you code it at that level? I feel that these are minor problems and don't justify a level 4, however, many of the coders in my practice believe these should be a level 4.

I am just looking for any input.

Thank you for your time.

 

[Naveen Rachagolla]

Documentation

It entirely depends on how doc is going to treat the patient and document the notes, and more over for est.pt only 2 components are needed and since as there are multiple infections, doc might exam the patient in detail and might go for additional work plan.

It purely depends on the MDM and the documentation of the note.

 

[ICD10CM/PCS]

It depends on the total documentation, how the physician has evaluated the patient and also any medication given to the patient. If no medication and no additional work up and plan. it will support 99213 level.

regards,
reddy.

 

[MnTwins29]

Agree with previous two posts

When there are multiple diagnoses being treated, it doesn't matter whether they are "minor" or not - it depends on what course of action is taken to treat them. Also keep in mind there could be medication interactions, reactions by the patient to certain treatment and the like that would make the MDM more complex.

 

[tmorehart]

Reply

I am just saying if there is one problem such as:
Otitis media or Strep or viral pharangitis no other co-morbidities documented

Est patient-new problem-meds-5+ systems examined and I have a 99214, however, I don't feel that it is appropriate to code this. There are differing opinions amongst my co-workers though.