Wiki question on MDM

[mrolf]

Our physicians do pre-op physicals and always bill 99214. The exam is comprehensive, History is EPF and the MDM I feel is Low, because there assessment states "patient is stable or healthy and cleared for surgery". However, in the Medical History the physician states"significant for HTN, very mild diabetes II and occasional palpitations with cardiac ectopy that is currently stable. Don't they have to state in their assessment the condition and its status in order to get credit towards MDM. How do I or an auditor know if these were addressed. Please advise. I just feel uncomfortable billing these as 99214 when the assessment states "stable and cleared for surgery".

 

[preserene]

What he says, "patient is healthy and cleared for surgery" denotes the preoperative assessment notes to say that he is fit for surgery. It is not the presenting problem or illness that goes into the history/examination for the presenting problem.What goes into the medical record of E/M Service is the later part of his notes of evalation,H/O HTN, and the mild diabetes, the examiantion related to the surgery cause and the preexisting deceases.
He has taken detailed history and comprehensive examination and the MDM level is with moderate complexity with assessment for surgery, from the info provided.So the E/M Service code is 99214.