Wiki E&M Level Question

[calorom2]

Looking for opinions as there is some debate as to what Initial Inpatient level E&M this should be 99221 or 99222. Thank you in advance as your responses usually decide these disputes!

REASON FOR CONSULTATION:
I was asked by Dr. XYZ to evaluate the patient with atrial fibrillation and rapid
ventricular rate.
HISTORY OF PRESENT ILLNESS:
Patient is a 56-year-old gentleman with past medical history significant for
end-stage renal disease, on hemodialysis; hypertension; and coronary artery disease status
post myocardial infarction and coronary stents. Additionally, he has right renal stent
and left subclavian stent. He was admitted for progressive shortness of breath. He has
history of recurrent right pleural effusion and has had multiple thoracentesis. He has a
trapped lung syndrome.
On 09/27/2017, he had right lung partial parietal pleurectomy, mechanical pleurodesis and
decortication. Last night, he developed atrial fibrillation with rapid ventricular rate.
He was placed on IV amiodarone drip in addition to Cardizem.
This morning, his ventricular rate is better controlled, 90s to 110 BPM. He complains of
right chest tube pain. He relates no chest pain similar to his infarction pain in 2012.
MEDICATION LIST:
Present medications;
1. Cardizem 30 mg q.6 hours.
2. Amiodarone drip.
3. Cefepime 1 g daily.
4. Ketoralac 30 mg q.6 hours p.r.n.
5. Morphine 2 mg p.r.n.
6. Albuterol ipratropium nebs.
7. Losartan 50 mg daily.
8. Flomax 0.4 mg daily.
9. Sevelamer.
10. Clonidine 0.1 mg p.r.n.
ALLERGIES:
PENICILLIN.
PAST MEDICAL HISTORY:
As above. He has history of chronic atrial fibrillation. He has AV fistula in the left
upper arm.
SOCIAL HISTORY:
He continues to smoke cigarettes. He denies illicit drug use.
FAMILY HISTORY:
Not pertinent to present illness.
REVIEW OF SYSTEMS:
As above. A 12-point review of systems is reviewed and noted. No recent fevers, chills,
cough, or sputum production. He has had progressive shortness of breath and dyspnea on
exertion with his daily activities prior to admission.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.5, pulse 117, blood pressure by a-line 72/40, respirations
16.
HEENT: He is anicteric. PERRLA. No xanthelasmas. Flat JVDs.
LUNGS: With bibasilar crackles.
CARDIAC: Irregular rate and rhythm. 2/6 systolic murmur left lower sternal border.
ABDOMEN: Soft and nontender.
EXTREMITIES: Show peripheral edema.
LABORATORY & X-RAY DATA:
Chest x-ray, stable right pleural effusion, right apical chest tube, cardiomegaly.
ECG, atrial fibrillation, heart rate 100 BPM, left axis deviation, diffuse nonspecific
ST-T abnormalities.
WBC 18.1, hemoglobin is 9.4, hematocrit is 28.9. INR is 1.2. Sodium 133, potassium 7.0,
chloride is _____, BUN is 54, creatinine is 8.39.
IMPRESSION:
1. Atrial fibrillation with rapid ventricular rate.
2. Coronary artery disease status post coronary stent.
3. End-stage renal disease, on hemodialysis.
4. Status post right pleurodesis and decortication.
PLAN:
1. Continue IV amiodarone 24 hours. Can switch to amiodarone 200 mg b.i.d. thereafter.
2. Continue Cardizem.
3. High-risk CHADS-VASc score. Not able to anticoagulate currently due to recent
surgery.
Thank you for allowing me to contribute to the patient's care.
Thank you for this consultation.

 

[thomas7331]

I would code this as 99221 because the exam is not comprehensive. Some auditors will say also that the history is not comprehensive because the ROS does not document that all systems were reviewed. Otherwise than these, I think it would have met all of the other required elements for 99222.

 

[calorom2]

I would code this as 99221 because the exam is not comprehensive. Some auditors will say also that the history is not comprehensive because the ROS does not document that all systems were reviewed. Otherwise than these, I think it would have met all of the other required elements for 99222.

I agree but keep being told that the notation below covers the ROS. Thank you!

REVIEW OF SYSTEMS:
As above. A 12-point review of systems is reviewed and noted.

 

[thomas7331]

The exactly language from the CMS E&M documentation guidelines is as follows, with my emphasis added:

"A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems...At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented."

Although this guidance is objectionable to many physicians and likely outdated, and payers are becoming more interested in what patient problems were treated than in how a ROS is worded, a lot of auditors still do follow it strictly. A "12-point" review is not really meaningful and does not clearly show that the provider reviewed all systems, so it could put your codes at an audit risk unless you are prepared with a persuasive way to explain that it does.