Wiki Help with level 99215

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ny2scgirl

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My provider wrote this note and coded as a level 99215. I don't think that is correct. I'm thinking 99213. Thoughts?

Reason for Appointment
1. Followup Multiple Medical Problems
History of Present Illness
Advanced Care Planning:
Here for sch'd apt
She Feels "ok"
She is still undergoing HD every T-Th-Sat
She feels cold often
She has poor appetite, she denies weight loss.
Vital Signs
Nurse: Temp: 97.7 F, HR: 69 beats per min, RR: 17 breaths per min, O2 sat %: 95 %, BP: 102/56 mm Hg, Wt: 86.1 lbs, Ht: 62.5 in, BMI: 15.5 Index, Wt-kg: 39.05 kg, Ht-cm: 158.75 cm.
Examination
General Examination:
GENERAL APPEARANCE: thin, elderly, frail, alert, well hydrated, in no distress.
HEAD: normocephalic, atraumatic.
EYES: BOTH EYES, eyelids normal, conjunctivae normal, sclera non-icteric.
EARS: auditory canal clear, TM w normal light reflex and mobility.
ORAL CAVITY: good dentition, gums normal, mucosa moist, no lesions.
THROAT: no erythema, no exudate, pharynx normal.
NECK/THYROID: neck supple, no cervical lymphadenopathy.
HEART: regular rate and rhythm, S1, S2 normal, no murmurs, rubs, gallops.
LUNGS: clear to auscultation bilaterally.
CHEST: normal shape and expansion.
EXTREMITIES: no clubbing, cyanosis, or edema.
PERIPHERAL PULSES: 2+ radials w brisk capillary refill time,no carotid bruits.
NEUROLOGIC: cognitive exam grossly normal, cranial nerves 2-12 grossly intact.
Assessments
1. Hypertension, unspecified type - I10 (Primary)
2. Hyperlipidemia, unspecified - E78.5
3. End stage renal disease - N18.6
4. Dependence on renal dialysis - Z99.2
Treatment
1. Hypertension, unspecified type
Notes: High Blood Pressure: Care Instructions material was printed
Clinical Notes: Now seemingly resolved since her kidney dz progressed to ESRD
Off meds

2. Hyperlipidemia, unspecified
Clinical Notes: now off statin tx

3. End stage renal disease
Clinical Notes: unchanged
On HD
Follows with Dr. Murphy

4. Dependence on renal dialysis
Clinical Notes: unchanged
 
Agree with you that this is not a 99215.

Did this provider discontinue the statin, or was the provider just observing that the patient doesn't take a statin anymore? To me, it sounds like just an observation. (If the provider did manage the statin on this visit, this would be a great example to educate the provider about documentation improvement.)

I would agree with you that the note only supports a 99213.

If the provider pushes back, I'd share this grid from the AMA and explain that 2 of the 3 elements of MDM must be met. Seeing the visual of what the AMA says actually qualifies for a 99215 might be helpful.


1724178373164.png
 
sls314 said:
Agree with you that this is not a 99215.

Did this provider discontinue the statin, or was the provider just observing that the patient doesn't take a statin anymore? To me, it sounds like just an observation. (If the provider did manage the statin on this visit, this would be a great example to educate the provider about documentation improvement.)

I would agree with you that the note only supports a 99213.

If the provider pushes back, I'd share this grid from the AMA and explain that 2 of the 3 elements of MDM must be met. Seeing the visual of what the AMA says actually qualifies for a 99215 might be helpful.


View attachment 7268
Click to expand...
Thank you :)
 
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