Well, it's just four weeks until our first conference this year. I'm excited about a lot of the new stuff we'll be talking about. This year a new item we will be covering is how to audit-protect your charts. I hope many of you can make our new conferences but I'm not going to hold this information as a secret. Next week I'm going to share several things that will help protect you during an audit.
This week, I'd like to pose a coding question. I'm not going to answer it until next week because I want you to think about it. Here goes:
41yo male with stable HTN controlled with Diovan comes in with complaints of 12 hours of severe vomiting and diarrhea that resolved yesterday morning. He states that he lost approximately 16# in 24 hours but drank a little over a gallon of Gatorade and today in clinic is still down 6#. He was febrile to 101.2 yesterday but no fever in clinic today. BP is normal. Remainder of history is negative. Physical exam is normal.
How would you code this visit? I think most of us would agree it would be a 99213 or 99214. But which one is it? How much history, physical exam, and decision-making did you do? What was the level of risk? Why? If you got audited on this chart tomorrow, would there be any issues with it? Next week I'm going to present you with two notes. The first one will be the 'standard' note that we would commonly do. In the second note, I'm going to apply several of the 'audit-protection' guidelines that we will be discussing in the new Coding Growth Strategies conferences this year.