Clinical Example #3: CPT Code Level 99204 (New Patient)/99214 (Established Patient)

The patient is 65 yo with CHF, DM, and HTN. The patient presents with leg swelling and erythema that began four days ago. The patient indicates there is some pain in the leg and is feeling feverish; however, there is no fever on vital signs.

ROS: Reviewed
History: Reviewed

Physical Exam: is suggestive of purulent cellulitis. swelling of leg.

Assessment and plan.
Records from PCP are reviewed and reveal the history of MRSA. The patient indicates no allergies. A complete blood count, comprehensive metabolic panel, and a wound culture are ordered. The patient is prescribed five days of oral doxycycline. Adverse effects of doxycycline are discussed with the patient. The case and management are also discussed with the patient’s PCP.
The patient is to return to the office in one week or sooner if the problem worsens.

Explanation: The problem is now a new problem involving a discussion with another provider and a review of historical records. The risk has now increased to a moderate level given the patient was given a prescription that may often lead to side effects; therefore, code level 99204 or 99214 is indicated.

NEW-MDM-Charts

Clinical Example #4: CPT Code Level 99205 (New Patient)/99215 (Established Patient)

The patient is 65 yo with CHF, DM, and HTN. The patient presents with leg swelling and erythema that began four days ago. The patient indicates there is pain in the leg. The patient is feeling very sick and is unable to provide a history. The patient’s daughter called and indicated that the patient has had a fever, malaise, and severe leg pain.

Physical Exam: The exam indicates a patient who appears very sick and has leg erythema and severe tenderness. The patient has no allergies. Vital signs reveal hypotension and tachycardia.

Assessment and plan:

The decision is made to send the patient to the emergency room for hospitalization and emergent surgical evaluation for possible necrotizing fasciitis. CBC, CMP, and blood cultures are ordered. It is recommended that the patient is started on IV vancomycin and piperacillin-tazobactam with vancomycin level monitoring. The case is discussed with the ER and surgical attending physicians. The patient is transported to the ER for admission.

Explanation:

Medical decision-making for this case is at the highest level given that the patient has a very complex problem necrotizing fasciitis that could threaten life or body function. The data reviewed is now more complicated in nature and involves speaking with an independent historian (the patient’s daughter), ordering tests, and discussions with emergency physicians and other attending physicians. The risk has now increased to a high level given the patient needs to be hospitalized and started on IV antibiotics, and there is consideration of emergency surgery; therefore, code level 99205 or 99215 is indicated.

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