Take the Quiz then click Show More to see the rationale.
CLICK THE SHOW MORE BUTTON FOR THE EXPLANATION BEHIND THE ANSWER.
How did you code it?
HERE IS WHY...
- This is a new patient. The bar is higher to bill at a level 3 with a new patient.
- It had a Chief Complaint. Did you know you can't bill any visit if you don't include the CC?
- It had 5 elements in the HPI. You only need 4 HPI elements to bill at a 99203.
- It had 4 elements in the ROS. Only 2-9 elements are required to count as an extended (not complete) ROS.
- It had both PMH and SH. Even if they have no PMH, a simple statement that they have no PMH counts. Also, SH is required to bill a 99203.
- 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.
- For medical decision making, this is a new problem with no additional workup planned; the presenting problem is minor, and it requires OTC drug management. This makes the medical decision making Low Complexity.
- The result of a detailed history + detailed exam + low complexity medical decision making = 99203. It takes all 3 of the 3 of these elements to bill at a 99203.
What if this was an established patient?
If you did exactly the same history, exam, and medical decision making as above for an established patient, as opposed to a new patient, this would technically be a 99214. However, we need to be cautious here. If your HPI or exam lacked only a few items, the complexity of medical decision making is low, so both the history and exam must be detailed. If your were in doubt, it would be reasonable to code this as a 99213.