Coding Q & A

Hey everyone! Here is a note I came across today (new patient):

History:
Chief Complaint: NP- RASH / UTI? / ER F/U
History of Present Illness:
Patient is a 2yo female here with complaints of 6 day history of a rash. Was seen in urgent care on Thursday and then ER yesterday. Was given Amoxil and prednisone. Has had some fever for 3-4 days but none in the last 24 hours. Now still having diffuse rash that is not improved.

(Complete ROS, PMH, Social Hx, and Family Hx on the note but not included here)

Physical Exam:
Vitals: Weight: 15.2kg Height: 96.52cm Pulse: 90 Resp: 24 Temp: 36.11
Constitutional: Normal/negative.
ENT: Very red swollen tonsils.
Cardiovascular: Normal/negative.
Respiratory: Normal/negative.
Skin: Moderate eczematous rash on trunk and all four extremities.

Procedures:
Strep Screen (87880): Rapid Strep Screen: Negative

Diagnoses:
1. FEVER (780.6)
2. ATOPIC DERMATITIS (691.8)
3. TONSILLITIS, ACUTE (463)

Treatment Plans:
1. Medication prescribed: Triamcinolone Acetonide 0.1% Cream APPLY TWICE A DAY AS DIRECTED. (Dispense: 240g; Refills: 3).
2. Follow-up: Next Scheduled Visit
3. Take tylenol or motrin as needed.
4. Use cetaphil cream 4+ times daily.
5. Encourage fluids.

How would you code this? At first glance I think this is moderate Risk (acute problem with systemic symptoms) and has at least 3 diagnoses/management options which gives a Moderate level of decision making. So right away I’m thinking 99204.

That is where I’ve made a mistake. Remember that new patients have different coding requirements from established patients. I have a comprehensive history, so that is not an issue. The issue is that I have to satisfy all three requirements (History, Physical Exam, and Decision Making). I have enough history for a level 5, enough decision making for a level 4, but my exam limits my note to a 99203. The only way you can have a 99204 is with a comprehensive (8 organ system) physical exam.

Don’t forget this when doing your coding. New visits require all 3 areas to be met (compared to 2 out of 3 for established). But also the amount of history and physical exam required is higher than the comparable established patient.

Advanced Coding Strategies

We have received a very positive response about our upcoming Advanced Coding Strategies Seminar. Here are the current details: It will be held on Saturday October 15th from 8:00am to noon in Dallas. We had announced that the venue would be the Courtyard Dallas Central Expressway, however, no sleeping rooms are available for the night of October 14!! Plus we have some attendees interested in flying in for this and want to move closer to the airport to make it more convenient for everyone. So, bear with us, we should have a location this week……the cost will be $250. We will be filming this presentation and the audio and video materials will be available by October 25. We hope the positive response will translate into a nice crowd at meeting time. We are utilizing a smaller venue for this initial course and seating will be limited.

More details will be available on the website and in the next few newsletters (the course is available on our website now). This course is intended to be a part 2 or ‘graduate’ coding course. It is intended for those of you that have already taken our basic Coding Growth Strategies course. We will give a simple overview of coding and then dive in to the many challenging cases that we are presented with in our typical daily practice. You’ve heard me say that “90% of the time if you find out the level of Risk, you then know how to code for the service.” This class goes in depth to the other 10% of the time.

One thing I’m very excited about is the “Challenging Cases” section. All attendees will be encouraged to submit 1-2 of their most difficult (or common) coding challenges. These will be printed and distributed to the group then as a group we will go through and pick them apart to see exactly the correct coding that should be applied to the note. And as always, if anything was overlooked we will definitely show where an additional piece of documentation could’ve made the difference for a higher level of service.

Sign up for the Advanced Coding Strategies live presentation

Pre-order the Advanced Coding Strategies DVD/CD (available October 25)