Wiki Would you code this a 99213 or a 99214?

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amexnikki23

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Provider is charging a 99214. I am trying to charge a 99213 with the rationale that this is an established problem worsening (2 pts), no data reviewed, and a moderate Risk due to the Rx management. But with a 2-0-moderate, I am still coming up with the 99213. Your thoughts:

CC: f-u anxiety
HPI: Anxiety: 31 year old male presents with ANXIETY F/U worsening for the last 2 months. He was out of work for some time and has to catch up on lot of things. He gets anxious about it. STRESSORS worsening, at work. PANIC ATTACKS more frequent panic attacks, several times per week. MOOD irritable, anxious, worried about everything, overwhelmed. SLEEP DISTURBANCE difficulty falling asleep sometimes, racing thoughts while lying in bed. CONCENTRATION mildly impaired.
PFSH documented (not entered here)
ROS: 5 documented (not entered here)
Vitals: documented (not entered here)
EXAM: 7 body areas or OS documented (not entered here)

DX: Generalized anxiety disorder - 300.02 (Primary)

Plan:
Treatment:
Generalized anxiety disorder
Increase sertraline tablet, 100 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 3
Start clonazepam tablet, 0.5 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 0
Clinical Notes: Will increase the dose of Zoloft and add Clonazepam as needed. Side affects discussed in detail. Will follow up periodically. Pt educated with multium medication printout.
 
This is an established patient so why can't you code a 99214 based on History and Exam? This patients seems pretty sick and I would definitely say Medical Necessity is met. According to the AMA guidelines in CPT, Moderate Nature of Presenting Problem (usually in a level 4) includes, "...increased probability of prolonged functional impairment." Sounds like a 4 to me.
 
I agree that your MDM is low. We're finding that our Medicare auditors are requiring the MDM to support the level in an established patient visit in cases where the History and Exam do make the code qualify, but the above post is correct that per CPT guidelines, History and Exam alone are sufficient.

A couple of thoughts to add: You haven't given us the exam documentation - if the 7 BA/OS are minimally documented or documented by check boxes only, that would be considered an EPF exam by some payers and wouldn't let your visit qualify for 99214. A more thorough exam would support a higher level, but an auditor could also ask why was a detailed exam necessary for the presenting problem of anxiety? The provider doesn't say why they thought that was necessary. Also, I think the provider's statement 'will follow up periodically' weakens the medical necessity argument on this note. A problem of moderate severity would typically need to be followed more closely and you would expect the provider to want to recheck the patient.

I think there's an argument to be made for both sides. I don't think 99214 would be fraudulent, but it might be harder to defend in an audit if challenged.
 
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