Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

CHOOSING E/M LEVEL

Maarit Posted Tue 20th of March, 2012 22:24:57 PM

1) Can a new PT dermatology visit ever be more than 99202?
HPI is always “expanded problem focused” because ROS is only about one system: skin
Any reason why a derm clinic could not review other systems as well?

2) Does a mention of the status of a chronic condition (which is not CC) in the HPI count as one data point?

3) Est. PT w/ new AK lesions is considered in MDM
a) established problem worsening or
b) new problem

4) SHOULD E/M LEVEL BE CHOSEN BY THE PROVIDER OR BY THE CODER?

SuperCoder Answered Wed 21st of March, 2012 06:43:02 AM

1). No, If HPI is EPF then the vist will never exceed level 2 as for a new patient we need all 3 key components
2). A derm clinic physician could review other system also depends upon the need & severity of the condition, For ex. if a patient comes to physician with a complaint of rash after a insect bite then there is no need to review or examine other system.
3). Any Est. Pt. with a new problem not related to prior illness should be consider as new problem.
4). Both

Maarit Posted Tue 27th of March, 2012 21:10:25 PM

Can you give me an example when it would be appropriate to review more systems than skin at a derm clinic?
Also, please tell me how many systems are reviewed in the below example?

Review of Systems

Denies poor wound healing, unusual hair distribution, nail changes, dry eyes, nose, or mouth, rashes or new FH of Melanoma.

The pt has a PMH of Melanoma , right posterior shoulder, 07/2009

The pt denies a previous hx of atypia or Actinic sun damage.

SuperCoder Answered Wed 28th of March, 2012 07:39:31 AM

More systems could be clinically appropriate. A few that come to mind to determine if systemic reaction to bite – rash may be precursor of more in depth reaction and bite can also cause concern of infection and insect carried diseases: constitutional, musculoskeletal, gastrointestinal.
In your example we can count 3 systems, Integumentry, Eyes & ENT.

Related Topics