Wiki Coding Office Levels

[CatieCass]

I have a patient chart at work who came in as a new patient and had an I&D done. Looking in her chart, I noticed two other issues that she had were that she is missing one kidney (congenital), and that she is currently being vaccinated for rabies (she was bit by a rabid animal). Nothing was done about these problems during this particular visit, but I think that because she has a congenital kidney condition AND rabies AND needed an I&D done, I should code it as 99204 rather than 99203, which is what I would have put if she had no other issues (that being the only procedure done). Coding for the level visit doesn't always have to do with JUST what was done during the visit. You also have to look at their conditions, etc. That being said, does anyone follow this and agree? Some feedback would be very appreciated. Thanks!

 

[skraft1969]

E/M

In order to bill 99204, you need to consider what the patient came in for... (chief complaint) The provider would have needed to document a Comprehensive history, performed a comprehensive exam, and the medical decision would need to moderate. Just because a patient has a congenital defect doesn't mean that you can code a higher level of e/m that could play a role if that defect affected the providers medical decision making. What you described about these conditions the provider documented but didn't treat is past medical history........that's it. Again, you need to look at the entire note and code based on what the provider documented.