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dballard2004

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A new patient presents to our office. The diagnoses are acute pharyngitis and a viral infection. The provider placed the patient on two differant antibiotics for these condtions. The provider performed a comprehensive history and exam which I get using both the 95 and 97 guidelines. This codes out to a 99204. All three key components meet here.

Now here is my dilema....I feel the provider overdocumented the exam here based on the chief complaint. The chief complaint was cough, fever, headache, nasal congestion/drainage, and sore throat.

I feel this should be downcoded to a level three (99203), but I know this provider will feel that the 99204 is appropriate based on the facts that the key components meet here and since this is a new patient a more through exam and history was required.

I would appreciate any and all thoughts or opinions here.
 
Medical Necessity is the key

dballard2004 said:
A new patient presents to our office. The diagnoses are acute pharyngitis and a viral infection. The provider placed the patient on two differant antibiotics for these condtions. The provider performed a comprehensive history and exam which I get using both the 95 and 97 guidelines. This codes out to a 99204. All three key components meet here.

Now here is my dilema....I feel the provider overdocumented the exam here based on the chief complaint. The chief complaint was cough, fever, headache, nasal congestion/drainage, and sore throat.

I feel this should be downcoded to a level three (99203), but I know this provider will feel that the 99204 is appropriate based on the facts that the key components meet here and since this is a new patient a more through exam and history was required.

I would appreciate any and all thoughts or opinions here.
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Hey Dawson,

I completely agree with your thought process/pattern. I used to have the same problems at one of my previous employers with over-documenting on these types of issues. I say stick with your guns and if necessary pull out the CPT book and highlight where it states about medical necessity.

Just to be sure, does the patient have any chronic conditions that could have played a part in MDM?
 
I have to disagree with you on this one Dawson. If they did it and documented it they get credit for it. This was a new patient, they have nothing to go on, why would the exam not be justified?

I am not clinical and I am not going to even try and tell a clinical person what is medically necessary and what is not. If you truly feel they are just padding documentation then that needs to go to whichever clinical person is over them to make that decision and address it.

Just my take on it,

Laura, CPC, CPMA, CEMC
 
My thanks to both of you! I'm really on the fence here. Roxanne, I do understand your point on medical necessity. This provider performed MS, Skin, Psychologic on the exam that I'm having a difficult time justifying based on the CC.

Laura, I do also see your side as well about this being a new patient and the provider not being familiar with this patient.

The key components do meet here indicating a 99204.
 
I have to agree with Katmyrn. The audit and E&M is based on documentation. I educate on medical necessity and documentation but I am not going to down-code the documentation because I don't think he had any reason to do a MSK or ENT exam etc. I am not in the room and I don't have MD behind my name so I am not going to tell the physician what kind of exam he should have done or argue with him on why he did an Abd exam on a patient with a sore throat.

A pattern of padding, over-documentation and cookie-cutter notes are all separate issues for Peer Review or QA.
 
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