Well, it looks like we've entered into flu season already. Or as I like to call it, 99214 season! That's right. One thing I've tried to teach over the years is to be sure and code your patients correctly. And once that is done, make sure and document your codes correctly. Many of you don't realize how the typical influenza patient is also a typical 99214. Let me give you an example of a very short note. This may not be the note you write. You may put lots more in it. But look at this example:
Chief Complaint: fever.
History of Present Illness:
Here with complaints of 2 days of fever to 102 and lots of coughing. OTC cold medicines haven't helped. Denies any other respiratory or GI symptoms.
Past Medical History:
Problem List:
A quick analysis would show the following: This note has a chief complaint, 5 elements of History of Present Illness ("2 days" is duration, "fever" is location, "102" is severity, "coughing" is associated signs and symptoms, and "OTC meds haven't helped" is modifying factors), 2 elements of Review of Systems ("Denies any other respiratory or GI symptoms"), and 1 element of Past, Family, Social History (Past Medical History). This qualifies for a Detailed History.
On physical exam, we have enough for a Detailed Exam ("an extended examination of the affected body area and other symptomatic or related organ systems").
In Medical Decision Making, we have Moderate Risk (an acute illness with system symptoms, plus prescription drug management), Minimal Data Review (1 point for lab), and Extensive Diagnoses/Management Options (4+ treatment plans). This would qualify for Moderate level of Decision Making.
For a 99214, you have to have 2 out of 3 of History, Exam, and Decision Making. We have 3/3 satisfied. This is a very typical (yet very simple) 99214 note and it should pass any audit without problems.