Coding Corner Answer

September’s coding answer: This visit would be considered not medically necessary because nowhere

in the notes does the rheumatologist acknowledge that he took the history of present illness (HPI).

The notes state that the patient reports the HPI to the nurse, not the physician.

Below is what the visit could have been coded had the HPI been taken by the physician:

This is an established patient outpatient/office visit and should be coded as 99213 because it included:

Expanded, problem-focused history: HPI has six elements; review of systems pertinent to problem; past family and social history is not addressed;
Detailed examination: five systems; and
Straightforward decision making: One stable problem improving, moderate risk for prescription drug management, no diagnostic studies ordered.

The diagnosis should be coded as 715.36

The levels of service within an evaluation and management (E/M) visit are based on the documentation of key components, which include history, physical examination and medical decision making. The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem. To…

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