January 25, 2011

By Paul Firth, MD
Founder and CEO
Medical Efficiency Systems LLC.

This is a free newsletter which focuses on helping physicians take charge of their businesses, enhance their practices, and increase their profits.

Hi Everyone!

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)

Coding Analyzer - question 1 answer

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

Coding Analyzer - next patient

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.

Coding Growth Strategies

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