If you're like me you are busy busy with all the sick visits you can handle.
Let's pick up our discussion from last week (which is also question #1 on the
Coding Analyzer)
History:
Chief Complaint: sick
History of Present Illness:
Patient here with complaints of fever with lots of coughing and URI symptoms for
2 days.
Past Medical History:
Allergies: NKDA
Physical Exam:
Constitutional: Ill appearing
Eyes: Red swollen soft tissue under bilateral eyes
ENT: Erythematous throat
Cardiovascular: Normal/negative.
Respiratory: Normal/negative.
Gastrointestinal: Normal/negative.
Procedures:
Influenza A: Influenza A: Positive
Influenza B: Influenza B: Negative
Diagnoses:
1. Influenza (487.1)
Treatment Plans:
1. Medication prescribed: Tamiflu 75mg Capsules TAKE 1 CAPSULE(S) BY MOUTH TWICE
A DAY FOR 5 DAYS (Dispense: Q.S.; Refills: None).
2. Take tylenol or motrin as needed.
3. If no improvement in 2-3 days, call or return to clinic.
4. Take over-the-counter cold medications as needed.
5. Encourage fluids.
6. No school/daycare for 48 hours.
This patient should be coded as a 99214. Why? Let's look at the requirements: We
must have 2 out of 3 for History, Physical Exam, and Decision Making. As in all
of my teaching, we will start with Decision Making.
Decision Making for a level 4 patient requires 2 out of 3:
Moderate amount of Diagnoses/Treatment plans
Moderate amount of data review
Moderate risk
We have a moderate amount of treatment plans. Prescribing medicine and patient
instructions all count as treatment plans (we have 6 total).
We do not have a moderate amount of data review.
We do have Moderate Risk. According to the 1995 Medicare guidelines, either
prescription drug management or an acute new problem with systemic symptoms
qualifies as a moderate level of risk. We have both.
We do not have enough history for a level 4 note. However, we do have an
'extended examination of the affected body area plus other related organ
systems'. So our Physical exam meets the requirements for a 99214 (Detailed
Physical Exam).
So, this influenza patient described above is a 99214.
If you have not yet completed the coding analyzer, take 5 minutes and
click here
History:
Chief Complaint: follow-up of Asthma.
History of Present Illness:
Patient is here for follow up of Asthma (stable). Symptoms currently well
controlled. No side effects reported.
Past Medical History:
Problem List:
1. ASTHMA (493.90)
Medications:
1. Asmanex Twisthaler 220mcg Inhalation Powder TAKE 1 PUFF EVERY BEDTIME.
2. Proventil HFA Oral Inhaler TAKE 2 PUFFS AS NEEDED.
Allergies: NKDA.
Physical Exam:
Constitutional: Normal/negative.
ENT: Normal/negative.
Cardiovascular: Normal/negative.
Respiratory: Normal/negative.
Diagnoses:
1. Asthma (493.90) (Stable)
Treatment Plans:
1. Medication continued: Asmanex Twisthaler 220mcg Inhalation Powder TAKE 1 PUFF
EVERY BEDTIME.
2. Medication continued: Proventil HFA Oral Inhaler TAKE 2 PUFFS AS NEEDED.
3. Follow-up: 3 Months
4. Keep peak flow diary bid.
How would you code this note and patient? Answers to follow next week.
For those that are debating attending or purchasing a Coding Growth Strategies
product, I've posted the first hour of the new 2011 Coding Growth Strategies
here:
Coding Growth Strategies Preview