Wiki Help coding 99395 &99213-25

[sauls]

Hello all,

i am trying to figure if this documentation with support a 99395 and 99213-25, the 99395 is out of question and was paid but it is not clear to me if an additional sick visit can be billed.
Here is the story:

Patient had a complete well woman exam with pap. Coded a 99395 (39 years old at that time) and some blood work, which is correct and supported by documentation.



In addition, the provider addressed hemorrhoids and hypothyroidism, which was coded with a 99213 – 25.



Here is my explanation for the 99213, am I missing or over coding something? I appreciate your comments.

Problem focus History
Chief complaint.

Under the patients History form the patient listed this 2 condition (hemorrhoid and hypothyroidism) and it was signed off by the provider.

HPI.

I could only find one element for hypothyroidism, about having her last thyroid function test done in 2008.

ROS

Can be shared with the physical and she has also, documented positive for rectal pain and anal spasms.

Pfsh

Can be shared with the physical and they there are all present.



Physical Exam.



At least one related system documented properly and abnormal finding listed for hemorrhoids. Expanded problem focus Exam.



MDM = Low complex or straight forward.

Hemorrhoid and hypothyroid are not optimized, which would equal to 2 points under “number of diagnosis”

Labs ordered for hypothyroid and a referral to GI doctor one or two points under “amount of Data”

Would this be a supported to code the 99213 or maybe a 99212 in addition to physical?

Thanks
Saul

 

[LLovett]

I would really rather see the note before I comment. You can't "share" the history or exam elements. The problem visit must stand alone. Generally when I code both physicals and problems I base the problem visit strictly on history and mdm. The fact the patient had a thyroid test in 2008 and is here for a physical, is more a personal history element to me than an element of HPI.

Laura, CPC, CEMC

 

[sauls]

thanks for your reply, Laura. Point taken. even if there is not HPI, ROS has at least 2 systems checked. PE is accetable and MDM Stright forward.

Just becuase the HPI was left out, does that mean Then EM would not stand alone?
appriciate any comments.

S