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jenneverett

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Newport, ME
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All PHI has been removed....
He has coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, diabetes, and history of prostate cancer. He presents here today with the complaint of headache. This is a follow-up visit. he has neck and shoulder pain on the left side that has been going on for a couple weeks, it gets better when he is up out of bed, he also woke up with diarrhea this morning.

HPI:
HEADACHE - The patient presents here today with a complaint of headache which has been present now for two weeks. It seems to be increasing. It is predominantly a left-sided headache in the temporal occipital area. He has discomfort that radiates down into his neck. His neck muscles on the left side feel sore and stiff. All of his symptoms are localized to the left side. He denies fever or chills. He denies fatigue or malaise. He denies any visual changes. He states he actually feels better if he is up and moving around. He seems to feel worse when he is lying down, especially at night trying to go to sleep. He has never experienced these symptoms before.

ROS:
CONSTITUTIONAL: Negative for chills, fatigue, fever, night sweats and unintentional weight loss.
EYES: Negative for blurred vision and eye pain.
E/N/T: Negative for diminished hearing, hearing aids and nasal congestion.
CARDIOVASCULAR: Negative for chest pain, palpitations, paroxysmal nocturnal dyspnea, pedal edema, syncope, presyncope and shortness of breath when laying flat.
RESPIRATORY: Negative for cough, dyspnea and frequent wheezing.
GASTROINTESTINAL: Negative for abdominal pain, acid reflux symptoms, heartburn, nausea, black tarry stool and blood in stool.
GENITOURINARY: Negative for dysuria, hematuria, painful urination and difficulty starting or stopping urine.
MUSCULOSKELETAL: Negative for joint pain, back pain and muscle pain.
INTEGUMENTARY: Negative for change in skin or hair texture.
NEUROLOGICAL: Positive for headaches ( unknown type ). Negative for balance problems, dizziness, fainting, numbness, slurred speech, tingling, tremor or weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising and excessive bleeding.
ENDOCRINE: Negative for feeling hot all the time and feeling cold all the time.

PMH/FMH/SH:
... Last Reviewed on 7/21/2014 9:04:25 AM by Mc
Past Medical History:

Coronary Artery Disease: 8/07 of the RCA and LAD with stent placement;
Hyperlipidemia
Hypertension
COPD
Sleep Apnea: uses CPAP;
Type 2 Diabetes
Prostate cancer: in biopsy stage, (7/25/2013);

CURRENT MEDICAL PROVIDERS:
Primary care provider
Orthopedist:

Surgical History:

Cholecystectomy
Coronary Artery Stent Placement: 11/20/09 proximal LAD, and in 2007;
Joint Replacement: hip; 8/2013;
Left Lung Cyst Removal (Benign);

Family History:
Father: Medical history unknown; Died at age 44
Mother: Died at age 91; Hypertension; Dementia
Brother(s): Coronary Artery Disease
Sister(s): Hypertension

Social History:
Occupation:
Retired
Marital Status: Married
Exercise: Primary form of exercise is walking. Frequency is 2 days per week. Tobacco: Past history of cigarette smoking; quit 1973.

Tobacco/Alcohol/Supplements:
... Last Reviewed on 7/21/2014 9:04:25 AM by Mc
Tobacco: He has a past history of cigarette smoking; quit date: Quit 40 years ago. Tobacco: Past history of cigarette smoking; quit 40 years ago.

Alcohol:
Drinks alcohol on a social basis only. When he drinks, the average quantity of alcohol is 2 drinks. He typically consumes wine and hard liquor.
Caffeine: He admits to consuming caffeine via coffee ( 5-6 servings per day ) and soda ( 4 servings per week ).

Supplements: Patient admits to use of COQ10, fish oils, and protandim, Vitamin D3.

Substance Abuse History:
... Last Reviewed on 7/21/2014 9:04:26 AM by Mc
NEGATIVE

Mental Health History:
... Last Reviewed on 7/21/2014 9:04:26 AM by Mc
NEGATIVE

Communicable Diseases (eg STDs):
... Last Reviewed on 7/21/2014 9:04:26 AM by Mc
Reportable health conditions; NEGATIVE


Current Problems:
Last Reviewed on 7/21/2014 9:04:25 AM by Mc
Abnormal EKG
CAD
Depression with anxiety
Fatigue
Hypertension
Leg pain
Mixed hyperlipidemia
Obstructive sleep apnea
Obstructive sleep apnea (adult) (pediatric)
Periodic limb movement disorder
Peripheral vascular disease
Headache

Allergies:
Last Reviewed on 7/21/2014 9:04:25 AM by Mc

Current Medications:
Last Reviewed on 7/21/2014 9:04:25 AM by Mc
Lotrel 10mg/40mg Capsules Take 1 capsule(s) by mouth daily
Doxazosin Mesylate 2mg Tablet Take 1 tablet(s) by mouth daily
Co Q 10 100mg qd
Fish Oil Capsules 1000 mg po daily
Flonase 50mcg/1actuation Nasal Spray 1 spray each nostril daily.
Optivar 0.05% Ophthalmic Solution Instill 1 drop(s) to affected eye(s) bid
Advair Diskus 250mcg/50mcg per 1blister Inhalation Powder
Diclofenac Sodium 75mg Tablets, Enteric Coated Take 1 tablet(s) by mouth qd
Nexium 40mg Capsules, Delayed Release 1 po qd
Patanase 0.6% Nasal Spray Use 2 spray(s) in each nostril bid
Crestor 40mg Tablet 1 po qhs.
Aspirin 81mg Tablets, Enteric Coated 1 po qd

OBJECTIVE:

Vitals:

Current: 7/21/2014 9:05:31 AM
Ht: 5 ft, 6 in; Wt: 175 lbs; BMI: 28.2
BP: 138/78 mm Hg (left arm, sitting); P: 72 bpm (finger clip, sitting, regular); sCr: 1.37 mg/dL; GFR: 43.06
O2 Sat: 98 % (room air)

Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished; alert and oriented X3, no apparent distress; well groomed;
EYES: sclerae non icteric and without hemorrhage, non erythematous conjunctiva and cornea are normal; PERRLA;
NECK: supple and symmetrical , JVP is 5 cm range of motion is normal; trachea is midline; thyroid is non-palpable; carotid exam is normal with good upstroke and no bruits;
RESPIRATORY: normal respiratory rate and pattern with no distress; clear in all fields percussion is normal without hyperresonance or dullness;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1 and S2 with no S3/S4 gallop, rubs or clicks; no systolic murmur; no diastolic murmur; 2+ carotid, radial, femoral, and pedal pulses; no cyanosis; no edema;
GASTROINTESTINAL: nontender; normal bowel sounds; no masses; no abdominal or renal bruits;
SKIN: capillary refill normal no obvious rashes or lesions
MUSCULOSKELETAL: normal gait; muscle strength: 5/5 in all major muscle groups; normal overall tone
NEUROLOGIC: cranial nerves: CN 2 - 12 grossly intact; sensation: grossly intact, symetric and within normal limits;
PSYCHIATRIC: appropriate affect and demeanor; normal psychomotor function; normal speech pattern; normal thought and perception;

ASSESSMENT:

784.0 Headache

PLAN:
HEADACHE - The patient presents here today with a complaint of headache which has been present now for two weeks. It seems to be increasing. It is predominantly a left-sided headache in the temporal occipital area. He has discomfort that radiates down into his neck. His neck muscles on the left side feel sore and stiff. All of his symptoms are localized to the left side. He denies fever or chills. He denies fatigue or malaise. He denies any visual changes. He states he actually feels better if he is up and moving around. He seems to feel worse when he is lying down, especially at night trying to go to sleep. He has never experienced these symptoms before.

The patient presents with two weeks of left-sided headache of unclear etiology. His neurologic exam was completely normal. I discussed the patient with Dr. Martin. At this time I am going to order a CT of the head without contrast. The patient is to call Dr. Martin's office today to schedule an appointment in the next couple of days to review the CT results. I will defer further recommendations to Dr. Martin.

I am looking at it and based on the documentation, 99213. Dr has a different opinion. What other documentation would you recommend be added to it, if any, to constitute a higher level visit? Our office has had an increase in random audits by payers and I want to be sure that we are on target with our billing.

Thanks for your help in advance!
 
I think you could go with a 99214 here. You have the history and exam to back that up. The physician probably thinks it should be a 99215, but the MDM isn't there to back it up. You always have the issue of the nature of the presenting problem as well. Even though this patient has multiple chronic illnesses and takes multiple medications, I can only come up with moderate for medical decision making based on stable chronic illnesses and one new problem with uncertain prognosis.

Lashel Church CPC, CEMC, CPC-I, CPPM
 
with an established patient per CPT guidelines you should be able to throw out the lowest element which in this case would be the moderate MDM. The problem with that is that per Medicare guidelines MDM and nature of presenting problem are over arching criteria. So even if you could squeeze out comprehensive history and exam, the nature of the presenting problem and the MDM would leave most auditors uncomfortable with a 99215.
 
Wow! That's a huge note but the only illness he's addressing in the HPI and the final A&P is the headache so that's all i would focus on. Personally, i dont think i would allow higher than a 99213. There's this concept called over documenting... :cool:

hope that helps!
 
I would go with a level 5. This is not a run of the mill headache. The doctor did a thorough and comprehensive work up looking for a cause and ruled out the usual suspects, leaving the need for a CT to look for subdural hematoma, aneurysm, or some type of intracranial pressure. He did a telephone consult with another doctor to discuss the complexity of this case.
 
I would go with the 99214..you def have your 2 out of 3 needed with the comprehensive physical exam and mod mdm since the doc ordered the CT (undiagnosed new problem). It can't be a 99215 since the doc didn't provide the time statement..
 
This is far more involved than a 99213. Billing a 99213 would be undercoding - which is also incorrect coding! If you want to bill on the safe side, 99214 would be the code, however, I do agree with MarcusM that this should be a 99215 as I don't think he over documented. Medicare says that the Medical Necessity is the over arching criteria for a level - not MDM. With a comprehensive history and exam and moderate MDM for an established patient this would be a 99215.

In the past, we had been audited by Highmark (now Novitas) and both of the 99214 visits audited with comprehensive history, exam and moderate MDM were upcoded to 99215 by them! We had 2 out of 3 for that level! And they even sent us the additional payment!
 
Last edited:
I just couldn't pull the trigger on the 5.

There is no severe exacerbation, no threat to life or limb, no change in neuro status, and no independent visualization of any test (I don't count calling the neuro exam normal as "independent visualization")

It's just a really bad headache right now. 99214 for me
 
And this is why this forum is so useful. Each of us has different opinions based on education and practical experience. I have a lot of clinical experience as well as coding experience and have witnessed too many providers under documenting their work and then griping when they don't get paid for what they actually did. One doctor actually told me, "Well, I know what I did." When I explained that his notes did not mention more than half of what he did, he replied that a first year med student should know what was involved. I replied that none of the 8 billers had ANY med school experience and we could only bill from his operative notes, he started being more thorough on his op notes, and getting paid more appropriately.
 
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