Hey everyone, today I want to start a series on writing the best 99214 note that you can. This is a topic that I have started discussion at this year's Coding Growth Strategies conferences. Over the past several years, I have tried to teach physicians how to both recognize what a 99214 patient 'looks like' but then just as important to teach how to write a good 99214 note. This year, I have changed my focus. Now I want to try to convey how to write a GREAT 99214 note.
So what is a great 99214 note? Here's how I define it: First off, see the patient and do the appropriate amount of History and Physical Exam. Wait a minute, you say, I always do that! That's right! The first thing to remember is that you do not have to have some 'template' or 'checklist' in your mind where you think "I've got to remember to do a certain amount of Review of Systems" or "I better remember to check at least 12 bullets on exam" or "I've got to put in the family history today or it won't be enough note."
Forget all those things! The first key is doing only the amount of history and physical exam that you think is necessary and important for that particular patient! How nice is that! There is nothing you 'have to remember' at all. In fact, I would go so far as to say if you are trying to put extra 'stuff' in the note that you wouldn't have done anyways then you might be guilty of up-coding your level of service.
Once you've done the appropriate History and Physical Exam for that patient, then it is time to write the note. Let me remind you what is needed for a 99214: You must have at least 2 out of 3 of a Detailed History, Detailed Exam, and Moderate level of Decision Making. Most auditors consider a Detailed History to consist of a Chief Complaint (CC), 4 elements of History of Present Illness (HPI), 2 elements of Review of Systems (ROS), and 1 element of Past Family, Medical, or Social History (PFMSH). A Detailed Exam is either 12 bullets (1997 guidelines) or an 'extended exam of the affected organ system plus other related organ systems' (1995 guidelines). Moderate Decision Making consists of 2 out of 3 of Moderate Risk, Moderate amount of Data Review, and Multiple Diagnosis and Management Options.
So knowing that it takes 2 out of 3 of History, Exam, and Decision Making to write a 99214 note, how do we then write a great note? To me it is simple. First off I want to have a Moderate level of Risk on the majority of my patients (I'll talk about why in future newsletters). Then I want to satisfy all 3 requirements of History, Exam, and Decision Making. Why? Because if I'm audited, then I know that even if some part of some section of the note gets 'thrown out' for whatever reason, then I have still satisfied the 2/3 requirements. To me a great note is one that I finish then never worry about again if I get audited.
So how to write that note? That brings up the second key: Write the note with an eye to satisfying all of the requirements. I'm going to give more examples of this over the next few weeks. The simple version is this. When writing my note I think about the following things:
These things are the key. Over the next few weeks I'm going to give specifics about each section, then follow up with a few newsletters showing example patients and how they were documented. Also I will discuss when these patients should appropriately be coded as 99213 or 99215 patients.