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.
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)