Billing Strep Throat

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Click the Show More button for the explanation behind the answer.

How did you code it?

Are you surprised at the answer?  We checked this with our coding experts to make sure it was correct, and it is.

Here is why....

  1. This is an established patient.  The bar is lower to bill at a level 4 with an established patient.
  2. It had a Chief Complaint.  Did you know you can't bill for ANY visit if you don't include the CC?
  3. It had 5 elements in the HPI.  You only need 4 HPI elements to bill at a 4.
    HPI: He has had sore throat for 2 days, fever to 101.5F, worse with swallowing, severe enough to make him cry.
    1. Location 2. Duration  3. Associated symptoms  4. Context  5. Severity
  4. It had 4 elements in the ROS.  Only 2-9 elements are required to count as an extended (not complete) ROS.
  5. It had both PMH and SH.  Even if they have no PMH, a simple statement that they have no PMH counts.  But if you say "non-contributory" this does not count.  Also, a brief word on SH that counts is who accompanies a minor or a comment on smoking history in adults.
  6. Next it had a physical exam that included head, EENT, constitutional/VS, respiratory, and CV.  For a detailed exam, 2-7 systems must be documented.
  7. For medical decision making, this is a new problem with no additional workup planned; the presenting problem is minor, and it requires prescription drug management.  This makes the medical decision making Moderate Complexity.
  8. The result of a detailed history + detailed exam + moderate complexity medical decision making99214.  It only takes 2 out of the 3 elements to bill at a 99214.

What if this was a new patient?

If you did exactly the same history, exam, and medical decision making as above for a new patient, as opposed to an established patient, this would be a 99203.

Watch a 1 minute video of this on the AMA CPT App.

 
 
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