Alright so Iím going to take this first question. This was oneÖ actually, I got twice this
week so I said alright. Thereís a practice exam out there, I wonít say where. I reworded
it so I donít get in trouble. But two different people emailed me about it. So I said, ìOkay,
Iím going to go over this.î So hereís the question: A 60-year old woman comes in for
a second opinion for her sleep apnea. The physician documents an extended history. Sheís
had it for the past 4 months. Sleep is disrupted by frequent awakening and getting worse by
anxiety and snoring. Current medication that she is now on is not helping. An extended
review of systems indicate she feels tired all the time, has some joint stiffness and
night sweats. She is going through a divorce. Doctor performs a comprehensive exam and moderate
medical-decision making.
So this is from students who have either taken my Blitz or the course and I teach a method,
Locate your HEM in time which basically is sayingÖ well first, identify the location
or the category and subcategory of E&M. And in this case, the answers are 99203 and 204
which are office new patient codes. And then 214 is an established and 243, I think, is
a consult. So because theyíre coming in for a second opinion, we can cross off C and D.
Okay so itís now going to be 203 or 204 and thatís the tie breaker that we want to try
and figure out.
So hereís my little worksheet. I tell you to write on your exam booklet or even in the
real coding world, on your you know, whateverÖ wherever youíre keeping notes, Locate and
HEM. And the goal is to fill in the blank to the right. So for location, weíve identified
it as office new.
For the history, they didnít really come out and give us the history which often times,
in the board exam, they will do. But it did say the physician documents an extended history.
Well, for history and exam, they have problem-focused, expanded problem-focus, detailed and comprehensive.
So extended isnít one of those terms. So they technically did not provide outright
with the overall history level is. But for exam, they did. They said comprehensive exam
and moderate medical decision-making. So I put a C for the exam and I put an M for moderate
decision making for the medical decision making.
Now when you look in your CPT book, in the E&M section for office new, youíd see that
the C shows up on the level 5 or 99205. So for shorthand, we just put a 5. And the moderate
medical decision making shows up at a level 4. So so far, these are the two levels. We
need to figure out what the history is because for office new, we know that we need to meet
or exceed all 3 of the bullets for that exam.
So what this is doing is itís making us work for the history. So for the history since
we have to work for it, we need to turn to our history table that you hopefully wrote
in your manual. And you know what? Let me see if I can get my document camera up for
that.
Alicia: While sheís doing that, I was going to mention, this is classic for board exams.
Theyíre wanting you toÖ they know you know how to find codes but can you pick the right
code? By having to come up with the history, that shows them that you know how to pull
the history out of your documentation and pick the correct code.
Laureen: Okay so this is my page 3 of my CPT manual which you know, if you do the Blitz
or the course, youíll get a copy of this. This is what you want to write in your worksheet
and weíre trying to fill in these blanks. Okay, thatís what Iím trying to do on the
slide. So since weíre trying to figure out history, Iím going to go to the history table
that I wrote in and this is basically taking theÖ let me back up here just a little bit.
Alicia: I want to say I think you can make it smaller.
Laureen: Yeah, thatís what Iím doing. Howís that?
Alicia: Perfect.
Laureen: Okay so Iím a very visual person as youíve heard me say many times before,
if youíve listened to me on these videos because when I see paragraphs of text, itís
like Charlie Brown. Iím just not getting it. So I have to convert things to a visual.
So all of this table is from the guidelines in the pages that preceed this. So I just
took history present illness, I turn to the definition for HPI and I saw that there were
2 possible scores. Okay, you see that extended so that should look familiar. So an HPI, history
present illness can be either brief or extended. Well, they told us it was an extended, right?
Okay so the next piece of history is review of systems. And you can have no review of
systems done. You can have a problem pertinent which is basically one system, problem pertinent
thatís extended, that 2 to 9 or complete which is 10 to 14 systems. Now, review of
systems sounds a lot like the exam because youíre talking about cardiovascular, genito-urinary.
So it sounds like things that you would examine. But itís what I call the talking, not the
touching. It sounds a little perverted but theyíre asking the questionÖ the patient
questions about those organ systems because itís something that they canít measure or
palpate or you know, weigh. They have to find out you knowÖ. well you know, are you having
headaches too? You know, that kind of thing. They canít look at you and see that youíre
having a headache. You have to tell them.
And then the 3rd piece to history is the past family social history or someone recently
said, ìOh PFSH.î Like okay, whatever works. But thereís 3 distinct pieces, past history,
family history and social history. So if you see documentation for one or two of those,
itís considered a pertinent PFSH. All 3, itís considered a complete.
And then hereís the 4 possible levels that we want to fill in on our H line down here,
P E D C ñ problem-focused, expanded-problem focused, detailed or comprehensive. Okay so
theyíre making us work for it on the slide, let me go back there real quick. Are you still
seeing my book or are you seeing the slide?
Alicia: Yeah, weíre seeing the book.
Laureen: Oh okay. How about now?
Alicia: There we go, back to the slide.
Laureen: Okay soÖ there we go. So the HPI is extended. The ROS was extended. The past
family social history is pertinent because when you read about it, it was just really
talking about sheís going through a divorce. Okay so when you go back to the table, weíre
trying to plug in, extended, extended pertinent. And the extended weíll see will come out
to a C. The extended ROS comes out to a D and the pertinent comes out to a D. So letís
see how that works out. Extended, extended, pertinent. Alright so hereís extended, hereís
extended and hereísÖ thatís not what I was looking for. What did I say? One of them
came out to a C. Oh okay, here we go.
So since extended on this one, it shows up on both levels, we always give them a higher
one. We always give them the most credit that we possibly can that they document it. So
thatís why the HPI is going to get a C. Okay but the extended for ROS only shows up at
this row so they get a D and then the pertinent gets a D. And when you put that all together,
since this is a 3 of 3 table, the lowest wins. And the lowest in this case is going to be
the detailed. Alright?
So now we come along and now we canÖ where we had not provided out right, we figured
it out. Itís a D, itís a detailed. And when we turn to the 99203 and 4 code, we can see
when itís 3 of 3, we code to the lowest. So whatís the lowest between a level 3, 4,
and 5? The level 3. Okay so the answer to this case is 99203. The reason this kept coming
to me is they had it wrong in the answer key. They were telling them it was B or it was
99204. So thatís where the confusion was coming and they thought they were doing this
pattern correct but how they tricked them was they used this extended history. And theyíre
thinking, ìOh, E-extended.î But itís actually expanded problem-focused history. So you had
to go back and really look at it closely and use that table.
So for those who havenít taken their certification exam, the heads up for you is that it used
to beÖ thereís about 10 questions on E&M on the board exam. About 2 of the 10, I used
to say, they make you work for it. Now Iím hearing itís more like 4 to 5 of the 10.
So definitely make sure you write your tables in and your CPT manual so you can use them
to help you figure out the missing slot.
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