Anatomy of a 99202

Can you spot a 99202 chart?

Case A

This is a new patient.

CC: Ankle pain
HPI: This is a 45 year old man with right ankle pain.  It is severe, 6/10 intensity. It is most painful over the dorsolateral aspect of the ankle.  It began after he inverted it stepping awkwardly from a curb 30 minutes prior to arrival.
ROS: No fever or constitutional symptoms; No rash or bruising of the area; No sensory or motor loss of the right lower extremity.
PMH: Hypertension
Exam: Gen: He is awake, alert, in mild discomfort; VS are as noted 155/85, 85, 16, 98%RA, 37C; The right ankle has mild tenderness over the anterior talofibular ligament but he is able to bear weight. No other abnormalities of the R lower extremity. He has normal sensation in the right foot and normal motor power.  R d.p. and p.t. pulses are readily palpable.  Skin shows no bruising or breakdown in the affected area.
Assessment: R ankle sprain
Plan: He will take OTC ibuprofen as needed for pain and use ice for comfort. RTC as needed. No x-ray.


Case B

This is a new patient.

CC: Ankle pain
HPI: This is a 45 year old man with right ankle pain.
ROS: No sensory loss in the right foot or ankle
PMH: Hypertension
Exam: The right ankle has mild tenderness over the anterior talofibular ligament but he is able to bear weight. No other abnormalities of the R lower extremity. He has normal sensation in the right foot and normal motor power.
Assessment: Right ankle sprain
Plan: He will take OTC ibuprofen as needed for pain and use ice for comfort. RTC as needed. No x-ray.


Case C

This is a new patient.

CC: Ankle pain
HPI: This is a 45 year old man with right ankle pain.  It is severe, 6/10 intensity. It is most painful over the dorsolateral aspect of the ankle.  It began after he inverted it stepping awkwardly from a curb 30 minutes prior to arrival.  He is not able to bear weight.
ROS: No fever or constitutional symptoms; No rash; + bruising of the area; No sensory or motor loss of the right lower extremity.
PMH: Hypertension
Exam: Gen: He is awake, alert, in mild discomfort; VS are as noted in the triage assessment; The right ankle has tenderness over the right lateral malleolus and he is unable to bear weight. No other abnormalities of the R lower extremity or foot. He has normal sensation in the right foot and normal motor power.  R d.p. and p.t. pulses are readily palpable.
Data: An x-ray of the R ankle shows a small avulsion fracture of the tip of the lateral malleolus. I personally reviewed and interpreted the x-ray.
Assessment: R lateral malleolus fracture
Plan: He will take OTC ibuprofen as needed for pain and use ice for comfort. We have placed him in a walking boot with crutches as needed.  He will RTC in 2 weeks for recheck.


Which is a 99202?

After you choose, click the button to find out the answer.

So, which did you choose?

The answer was Case B.  Why?

Case B was a 99202 because it had only one HPI element (location), one ROS element (neuro), and one aspect of PMH (no SH or FH).  This was Expanded Problem Focused.  The Exam included only the RLE and neuro assessment - Expanded Problem Focused.  This was a new problem with no data, an acute uncomplicated illness, and only required OTC medication - Low Complexity Medical Decision Making (MDM).  This is a 99202.

What about Case A?

Case A would be a 99203.  It had more than 4 HPI elements, >2 ROS, >2 exam findings, and low complexity MDM.  That means the history and exam were Detailed.  Did you notice this was the same case scenario as Case B?  Why was this a 99203 when Case A was a 99202?  By just adding a little more information to the HPI (which is important information to document anyway) and a few more exam findings (which are also important to document anyway), this is now a level 3 and not a level 2.

What about Case C?

Even with the more severe injury, x-ray, and fracture, this is still a 99203.  The HPI and Exam do not support a Comprehensive level.  The medical decision making is Moderate Complexity, but to bill as a 99204, both history and exam need to be Comprehensive.

Anatomy of a 99202

For a new patient, the documentation requirement for a 99202 is:

  • Expanded Problem Focused History: This means there are only 1-3 elements in the HPI, 1 ROS, and PMH only.
  • Expanded Problem Focused Exam: We use the 1995 criteria.  This means 2 body areas or systems must be documented.  To be considered a Detailed exam, 2-7 body areas or systems must be examined, and at least 2 organ systems must be completely examined.
  • Straightforward Medical Decision Making: In this case, the MDM was actually Low Complexity. That's because this was a New Problem with no additional workup planned.  Did you know, almost everything you see in retail medicine will be a New Problem?

Here's the deal...

If you only document enough to bill a level 2, you are probably not including enough meaningful information in the chart to effectively communicate clinically.  In this example, you would only have to say the patient had right ankle pain in the HPI.  This would be one HPI element, one ROS, and mention of PMH, which would count as an Expanded Problem Focused history.

But that would be terrible documentation.

What caused the ankle pain?

Was he run over by a steamroller?

Was he attacked by a manatee?

Does he have fever and do we need to consider a septic joint?

We don't know!

All of you include multiple elements in your History and Exam already, because that's just good medicine and good communication.

Why not get reimbursed at the appropriate level for the work you're already doing?

 

Again, did you notice that Case A and Case B were the same but Case A simply included the usual, slightly more extensive HPI and Exam, both of which are just normal, good documentation?  That alone is the difference between a 99202 and a 99203.

If you're practicing good medicine and doing good documentation, you deserve to be reimbursed for your work.

 

 

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