Advanced Coding Example

As I was seeing patients this morning I’ve come across another Advanced Coding Example. Now remember, Advanced doesn’t mean difficult, it just means it may be something you haven’t thought about.

Patient comes in today complaining of sore throat and URI symptoms. Strep was negative. No fever or other complaints. So I’m thinking 99213 (acute uncomplicated problem). When I get the strep test, I’m starting to type my note before going back in to talk to the patient. I look at the chart and notice they have a chronic diagnosis of asthma. They take albuterol prn and flovent just once daily. I go back in and give them the speech about ‘it’s a virus and you don’t need antibiotics.’ I ask about their asthma and it is very stable. Pat them on the head and send them on their way.

Now their diagnoses and plans look like the following:

Diagnoses:

  1. URI
  2. Tonsillitis
  3. Asthma

Plans:

  1. OTC cold medicines prn.
  2. Tylenol/motrin as needed for pain.
  3. Continue flovent and albuterol.
  4. F/U next month for flu vaccine.

Now we have a very appropriate 99214 (acute complicated illness). The acute illness is complicated by having an underlying chronic problem that has to be figured into the decision-making for this patient. Remember, we did not take a 99213 and turn it into a 99214. The patient by their very nature was a 99214. I just made sure and coded and documented appropriately.

Advanced Coding Strategies

The Advanced Coding Strategies Seminar will be held on Saturday October 15th from 8:00am to noon in Dallas. The cost will be $250 and includes course materials and breakfast. We will be filming this presentation and the audio and video materials will be available by October 25. You can pre-order the audio/video material at our website. 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.

October 15, 2011

Courtyard DFW Airport South
2280 Valley View Lane
Irving, TX 75062


For hotel reservation call 972-790-8990
Room rate is $79/night (for October 14)

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 at (available October 25)