Wiki Need help is this a 99214

Create Wiki
D

dpumford

Guest
Messages
299
Best answers
0
HI! I am hoping someone can explain to me how this meets a 99214..It is an E & M example I was doing to educate myself and I need HELP!

CC: Chestpain
HPI: 58 yr old femal with intermittent, sharp chest pain over two weeks. Episodes last 10 min at a time. Pain occurs at rest.

PH: Non-smoker, no family history of Cardiovascular problems.

ROS: No shortness of breath, No reflux

Exam: Vitals: BP 120/80, P 65
Lungs: clear to auscultation
CV: normal

A/P Chest pain. ECG and stress test ordered. Follow up scheduled.

This is an example of a 99214 and I am hoping someone can give me some insite. The Hpi and Ros is fine its the rest :confused:

Thanks in Advance:)
 
That is not a good or even realistic example

I am guessing they are basing it on Hx and MDM.

History is detailed, exam is problem focused 97 and expanded problem focused 95, MDM is really crappy but I guess they are saying this is a new problem with work up (4 dx points), 1 data point for ordering testing, and moderate risk for an undiagnosed new problem which gives you moderate risk.

Hope that helps,

Laura, CPC, CPMA, CEMC
 
I agree with Laura on the exam and MDM, but I'm still not sure that this is quite a 99214. The BP and pulse are not remarkable, and the CV exam notes "normal", which by CMS Documentation guidelines, is insufficient. There should never be a notation of "normal" without further elaboration, from the system chiefly responsible for the presenting problem. (That would be considered a 'pertinent negative' finding.)

That coupled with no prescription, advice, or tentative plan of care, gives the impression that the provider doesn't view the patient's condition as 'critical' or 'acute'; the tests could have been ordered, just to rule out any cardiac anomolies. Without at least a 50/50 chance of the condition worsening before the next visit being conveyed in the record, I'd be hesitant to make this a 99214, even though it technically meets the CPT requirements. I tend to be more conservative, though.
 
Someone told me once that in order for vitals to be considered a 'system' one had to document 3 vital signs. If so then this wouldn't qualify as 99214. Any comments?
 
3 or more vitals counts as 1 bullet for constitutional under 97 guidelines. There are no bullets in 95 so as long as 1 thing is listed related to that organ system or body area then you get credit for examining that system/area.

In this example the 99214 is based on Hx and MDM so it doesn't matter what level of exam you have.

Laura, CPC ,CPMA, CEMC
 
You must log in or register to reply here.
Top