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LewinFamily

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Can gross be used as severity? This is what my doctor is dictating:

"This is a 55 years old male who presents with hematuria. On a scale of microscopic to gross, the intensity is described as a gross"
I am thinking about giving it to him for severity.. but wanted to get your thoughts... It will make 4 components and make the level a 99215 instead of 99214 since he has a comprehensive exam already and complete PFSH and ROS.

Thanks!
 
No - the term GROSS as used here, refers to the examination - "the study of the structure of the body and its parts without the use of a microscope" - it is not severity, it is simply describing the level of study of the specimen. If he simply observed the urine specimen in the cup, that would be a "gross" examination. If he looked at it under the microscope, it would be microscopic.
 
This was actually in the HPI section not for examination.. I do understand UA being gross or microscopic but I believe the doctor is trying to describe the stage of hematuria and that is why he is stating gross vs microscopic..

What do you think?
 
I think in this case the doctor is using the term 'gross' to indict the severity. The doctor could have said he has "trace" "infrequent" etc.. The doctor also says that is their scale so it is a severity word, imo.

Perhaps you need to add it to your compliance manual since it a term the doc uses and you need to document what it means to the doctor.
 
99214 vs 99215

Even though you have two of three, remember to look at medical necessity before assigning a level 5. Was the case more complex than just hematuria??

LeeAnn
 
Yes.. In this case I agree that they are listing it as severity as well.

The MD has not stated that it's more complex than gross hematuria.. only hematuria and nocturia.
 
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