9. Coding Practice
A 16 year old outpatient who is a new patient to the office complans of severe facial acne. The history and physical examination are expanded problem focused. The physician must consider related organ systems in addition to the integumentary system in order to treat the condition. With minimal number of diagnoses to consider and the minimal amount of data to review, the physicians decision making is straightforward with regard to the treatment of this patient.
99202
A four year old female established patient received Evaluation and Management Services, which included a problem focused history, an expanded problem focused exam, and medical decision making of a low level. The patient is diagnosed with influenza.
99213
An established patient with a history of asthma presents in an office visit with acute bronchospasm and moderate respiratory distress. The physician conducts a problem focused history followed by a detailed examination, which shows a respiratory rate of 30. Office treatment is initiated: intermittent bronchial dilaton and subcutaneous epinephrine. This service requires the physician to have intermittent direct contact with the patient over a two hour period. The MDM compexity is moderate.
99214, 99354, 99355
A 55 year old female came in with the complaint of severe abdominal pain. The patient was admitted on 05-07 for observation due to the severity and location of her pain. The admitting physician performed a comprehensive history and a detailed examination and documented medical decision making of a moderate complexity given the amount of possible diagnoses, including appendicitis, gastric ulcer, cholelithiasis and pyelonephritis. Various diagnostic tests were ordered and done, including barium enema, upper gastrointestinal endoscopy, and KUB (kidneys, ureters, bladder) x-ray. No disease or disorder was found, and the patient was discharged from observation on 05-08. The patient reported a decrease in her pain after 30 hours of IV analgesics and antispasmodics. The physician documented that the patient should follow up with her primary care physician in 2 days or return to the hospital if the pain worsens. The physician also documented a final detailed examination of the patient and dictated a discharge summary report.
99218, 99217
A patient was in an automobile accident and is complaining of a minor headache and no other apparent injuries. HIstory gathered from the bystanders states that the patient was not wearing a seat belt and hit his head on the windshield. A 15 minute loss of consciousness was noted. The patient was then admitted for 24 hour observation to rule out head injury. A comprehensive history and exam are performed by the physician. The MDM is of moderate complexity.
99219
A 50 year old female patient was admitted to the hospital on 10-10 with a diagnosis of pneumonia due to Staphylococcus aureus, at which time she received level 2 E/M services from her attending physician. On 10/11 and 10/12 the patient received level 2 E/M services. On 10/13, the patient was dischared from the hospital in improved condition to follow up with the physician at home; the physician spent 30 minutes performing discharge day management functions.
99222, 99232, 99238, 99238
An established patient is seen in the hospital on day two of his hospital stay. The patient had been admitted through the emergency department with status asthmaticus and had been undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a detailed interval history and a detailed physical exam. The possibility of pneumonia complicating the asthma must be considered. The patient's respiratory condition is still unstable. The MDM complexity was high.
99233
A 52 year old patient was sent to a surgeon for an office consultation concerning hemorrhoids. An expanded problem focused history and examination were performed. The consultant recommended treating with medication after a straightforward MDM.
99242
A 13 year old male was admitted yesterday for a tympanotomy. Postsurgically, the child developed fever and seizures of unknown origin. A pediatric consultation was requested. This was done on the 2nd hospital admission day and 24 hours after surgery. The history of present illness (HPI) was extended with a complete review of systems (ROS). A complete past/family/social history (PFSH) was elicited from the mother as part of a comprehensive history. A comprehensive examination was conducted on all body areas and organ systems. The MDM complexity was high.
99255
A patient presents with the complaint of hematemesis. The patient also has a rapid pulse rate and low blood pressure. In the ED, critical care is provided by the ED attending to raise the patient's blood pressure and decrease blood loss. This is done for 70 minutes before the patient is transferred to the surgical suite for an endoscopic procedure to evaluate his esophagus. The ED physician also documents a detailed examination and MDM of high complexity. Due to the medical condition, he is unable to provide any history; no family is present to provide information.
99284-57, 99291
A patient in the emergency department has a tempuerature of 103 degrees F and is in acute respiratory distress. Symptoms include shortness of breath, chest pain and gasping. The physician is unable to obtain a history or perform a comprehensive physical exam because the patient's condition is critical. The MDM complexity is high.
99285
With 2 way communication, the physician directs the emergency medical technicians (EMTs) in an ambulance en route to the emergency department with a patient in apparent cardiac arrest.
99288
A physician is called to the intensive care unit to provide care for a patient who received second and third degree burns over 50% of his body due to a chemical fire. The patient is in respiratory distress and is suffering from severe dehydration. The physician provides support for two hours. Later that day, the physician returns and provides an additional hour of critical care support to the patient.
99291, 99292, 99292, 99292, 99292
A 72 year old patient suffered a cerebral vascular accident (CVA). Today, the patient is admitted to a skilled nursing facility (SNF) for rehab and medical care. The patient was just discharged from an acute care facility. The SNF medical director documents a comprehensive history, including the patient's chief complaint of paralysis and weakness, an extended HPI, and a complete ROS. A detailed exam of the patient's cardiovascular, respiratory, muskuloskeletal, neurological and genitourinary systems is documented. The physician orders a multidisciplinary rehabilitation care plan for the patient and the continued treatment of the patient's other medical conditions, including hypertension and diabetes. The MDM complexity is high.
99304
Subsequent follow-up care is provided for a comatose patient transferred to a long term care center from the hospital two days ago. The resident shows no signs of consciousness on examination but appears to have developed a minor upper respiratory tract infection with a fever and rales heard on ausculation. The physician performs an expanded problem focused history and a problem focused interval examination with respiratory status and status of related organ systems such as cardiovascular. The physician is concerned that the respiratory infection could progress to pneumonia and orders the appropriate treatment. The MDM complexity is moderate.
99308
A new patient diagnosed with mild intellectual disabilities and self abuse is sent to a custodial care for admission. The patient's family is no longer able to care for the patient at home. The care facility physician documents a problem focused history with a problem focused exam. The medical decision making documented was straightforward.
99324
A 21 year old patient with a recent history of drug abuse is admitted to a rehab center for treatment. In the patient's second week of treatment, she complains of back pain and is seen by the same physician who evaluated her medically upon admission. At this time, the physician documents a problem focused interval history, an expanded problem focused examination and MDM of moderate complexity.
99335
A 15 year old new patient has cystic fibrosis and is having problems with her Pulmozyme dosage. This medication is used to thin the mucus that clogs her lungs. The patient is having moderate throat pain and slight tightness in her chest. The physician makes a home visit to gather HPI and ROS and pertinent past personal medical information for a detailed history. The detailed exam focuses on the body systems currently affected by the cystic fibrosis and related organ systems: ears, nose, throat, mouth, respiratory, gastrointestinal, , and cardiovascular. The MDM complexity is of a moderate level.
99343
A 64 year old patient has diabetes and has been having problems adjusting her insulin doses. She has had an onset of dizziness and sensitivity to light. Her primary care physician, who has treated her for this condition for the past 4 years, makes a home visit today. At this visit, the physician gathers a brief HPI and a problem pertinent ROS during the problem focused history. The physical exam focuses on the body systems currently affected by the diabetes. The patient's condition is moderately severe, and the MDM is of a moderate level.
99348
A patient was in the delivery room ready to give birth. When the physician had the patient start pushing, possible complications for the infant were noted and the hospital pediatric neonatal specialist was notified of a possible need for her evaluation of this newborn. The pediatric specialist was notified at 9:20 am. At 10 am, she was informed via phone call from the OB/GYN that the infant had normal Apgar scores of 9 and 9.
99360
A 14-year-old boy twisted his ankle while playing soccer. He received level 3 E/M services from his physician the next morning for which code 99213 was reported on the CMS-1500 claim generated immediately after the visit. The physician ordered an x-ray of the ankle, and the child left the office after the x-ray but did not see the physician. Later that afternoon the patient and his mother came into the office and met with the physician, an orthopedic surgeon, and a rehabilitation therapist. Medical discussion was 45 minutes in duration.
99366
A 72-year-old patient with a history of breast cancer has a suspicious mass in her uterus. A biopsy was done. The determination was that the patient had a carcinoma in situ of the uterus. The physician who conducted the surgery called a face-to-face meeting with his fellow surgeons and discussed the case and the patient's outcome for 30 minutes.
99367
A 75-year-old patient was just diagnosed with type 1 diabetes. This means that the patient will have to give himself insulin shots. The physician supervised the coordination of home health care, which required 30 minutes of his time.
99375
A 50-year-old female has brain cancer, and the physician supervised the coordination of hospice services, which required 45 minutes of his time.
99378
A 13-year-old new patient presents for a well-check examination. The patient does not report any medical complaints.
99384
A 75-year-old established patient presents for his annual physical examination. The patient's chronic conditions are well controlled with diet and exercise.
99397
A physician called an established patient to inform her that the results of a chest x-ray were negative. The call was 5 minutes in duration. The patient had previously been seen in the office 10 days ago.
99441
A patient emailed his physician to ask whether taking 500 mg of cinnamon tablets daily would be acceptable, given the prescribed medications he takes. The physician replied, approving his taking 500 mg of cinnamon tablets daily. The patient had previously been seen by the physician in the office 15 days ago, and he is scheduled to receive office E/M services in 60 days as part of his routine care.
99444
A 58-year-old man was seen by his private physician for an examination as part of his claim for long-term medical disability. The patient has chronic obstructive lung disease with severe emphysema and has been unable to work during the past year. The physician documents a comprehensive medical history and a detailed examination. The physician reviews the patient's current medical treatment plan and recommends that it continue. All of the necessary documentation required by the insurance company is completed, including the physician's opinion that the patient would be unable to work in the future, as his pulmonary function is markedly impaired in spite of continual respiratory and pharmacologic therapy.
99455
A full-term healthy newborn girl received initial and subsequent hospital care services on July 7 and July 8, respectively.
9946, 99462