Evaluation and management billing level analysis for three clinic patients

Medical Billing/Coding Analysis for 3 patient visits:

Instructions: after reading the clinic notes for each of the 3 patient above, determine the level of billing based on the history, physical exam and complexity of medical decision making. You can highlight your choice in each category, but be sure to provide your rationale for your choice, based on the Medicare Evaluation Management guidelines (located in Module 4 documents). In the final row, select the overall level of billing for this visit, and provide your brief rationale for this level.

Example: Pt.#1 History: If I had highlighted "expanded problem focused," my rationale should include # elements addressed and # body organs/systems included to support the level I selected.

Patient 1: Stephens

Patient 2: Thomas

Patient 3: Evans

History

Problem focused

Exp problem focused

Detailed Stephens

Comprehensive

Rationale: There was a detailed family and personal history provided as well as at least six different systems examined.

Problem focused

Exp problem focused

Detailed

Comprehensive Thomas

Rationale: The patient and doctor discussed eight different areas of concern along with a limited family and personal history. Along with the eight areas, a discussion was launched with the patient that included a number of areas of concern that had not been addressed within the last 12 months (and in fact it had been over 2 years since the patient had been examined).

Problem focused

Exp problem focused Evans

Detailed

High Complexity

Rationale: In Stephen's case there was limited risk of morbidity, a moderate amount of complexity, and a minimal diagnosis. Averaging the three components makes this a limited rationale.

Straightforward

Low complexity

Moderate complexity - Thomas

High Complexity

Rationale: Giving Thomas the benefit of the doubt in regards to morbidity, the patient still has plenty of areas of concern that need to be addressed. Additionally, the patient has a family history of HTN as well as being a candidate due to the fact that he is an at-risk patient.

Straightforward - Evans

Low complexity

Moderate complexity

High Complexity

Rationale: One diagnosis was achieved with limited morbidity, and very little risk of complications.

Billing level

99203 - Stephens

Rationale: Stephens had a detailed history, a comprehensive physical exam, and a low complexity decision making process.

99205 - Thomas

Rationale: This patient had a number of areas of concern, was given a comprehensive physical exam and history, and a diagnosis of moderate complexity.

99202 - Evans

Rationale: There was a straightforward diagnosis with low to moderate severity.