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Medicare Coding and Billing

Medicare Coding and Billing.

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Medicare Coding and Billing

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  1. Medicare Coding and Billing

  2. A 50-year-old auto mechanic who is a new patient complains that his left eye feels like some debris fell in it while he was working under a car earlier in the day. Acuity in the eye is 20/25, injection is only 1+, and slit lamp examination reveals a foreign body retained under the upper lid, which is removed by irrigation with saline. There is minimal corneal compromise, and no medications are prescribed.New patients 99201 99202 99203 99204 99205 Established patients 99211 99212 99213 99214 99215

  3. New Patients Require All 3 LevelsCode History Exam Decision Making99201 Problem focused Problem focused Straightforward99202 Expanded problem focused Expanded problem focused Straightforward99203 Detailed Detailed Low complexity99204 Comprehensive Comprehensive Moderate complexity99205 Comprehensive Comprehensive High complexity

  4. Problem-focused history: CC, brief HPI (1-3 elements)This case: CC, 3 HPI(location, severity, duration)Problem focused exam: 1 to 5 elementsThis case: VA, conjunctiva, adnexa, corneaStraightforwarddecision-making:minimal diagnoses, minimal data reviewed, minimal riskThis case: straightforwardAnswer: 99201

  5. An alert 64-year-old male who is not a current patient seeks care for reduced visual acuity that seems to be worse in the right eye. ROS reveals that he has diabetic retinopathy (like his brother), for which he has received laser treatment one year previously (his last eye examination), systemic hypertension, and renal disease, for which he is taking several medications (which he can identify). Refraction yields OD 20/40 and OS 20/30 best corrected acuities. External assessment, pupils, and motilities are unremarkable, as are fields, but slit lamp and dilated fundus examination reveals cataract (OD>OS) and moderate diabetic retinopathy. Intraocular pressures are normal. After discussion of the findings, the patient opts to return in 6 months rather than see a cataract surgeon. The status of the diabetic retinopathy will also be reassessed at that time.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  6. New Patients Require All 3 LevelsCode History Exam Decision Making99201 Problem focused Problem focused Straightforward99202 Expanded problem focused Expanded problem focused Straightforward99203 Detailed Detailed Low complexity99204 Comprehensive Comprehensive Moderate complexity99205 Comprehensive Comprehensive High complexity

  7. Comprehensive history: CC, extended HPI (4 elements) complete ROS (10), complete PFSH (3)This case: CC (VA), 4 HPI (OU, OD>OS, with correction, longstanding), ROS, 3 PFSH (diabetes surgery, brother affected, concerned with health)Comprehensive exam: 12 elementsThis case: all 12, orientation to time, place, personModerate complexity decision-making: multiple options, moderate data, moderate riskThis case: moderate complexityAnswer: 99204

  8. A 25-year-old female seeks treatment for pain, tearing, and redness of the right eye. She is not a current patient. The discomfort began about three days earlier and is becoming worse. Upon questioning, the patient indicates she has experienced flu-like symptoms the past week. Her preauricular lymph nodes are tender and palpable bilaterally. Acuities are normal but slit lamp examination reveals an injected eye with a quiet anterior chamber, superficial corneal staining and no infiltrates. Warm compresses and artificial tears are instituted. New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  9. New Patients Require All 3 LevelsCode History Exam Decision Making99201 Problem focused Problem focused Straightforward99202 Expanded problem focused Expanded problem focused Straightforward99203 Detailed Detailed Low complexity99204 Comprehensive Comprehensive Moderate complexity99205 Comprehensive Comprehensive High complexity

  10. Expanded problem-focused history: CC, brief HPI (1-3 elements), pertinent ROS (at least 1)This case: CC (red eye), 4 HPI (OD, VA OK, tearing, 3 days), 2 ROS (eye, lymphatic)Expanded problem focused exam: at least 6 elementsThis case: VA, conjunctiva, adnexa, cornea, anterior chamber, iris and pupilStraightforward decision-making:minimal diagnoses, minimal data reviewed, minimal riskThis case: straightforwardAnswer: 99202

  11. A first-presenting 22-year-old male complains of a black eye and decreased acuity following a blow (from a fist) to his left eye received the preceding evening. Acuity is 20/30, by slit lamp there is a subconjunctival hemorrhage, a mild central corneal abrasion, and the pupil response is sluggish. A traumatic iritis is present, excursion of the eye is painful, but there is no sign of traumatic cataract. Fields are full. Because of significant swelling, it is decided to defer IOP measurement and dilated fundus examination. Cold compresses, a cycloplegic and an antibiotic are prescribed, and the patient is instructed to return the next day.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  12. New Patients Require All 3 LevelsCode History Exam Decision Making99201 Problem focused Problem focused Straightforward99202 Expanded problem focused Expanded problem focused Straightforward99203 Detailed Detailed Low complexity99204 Comprehensive Comprehensive Moderate complexity99205 Comprehensive Comprehensive High complexity

  13. Detailed history: CC, extended HPI (4 elements), extended ROS (2-9 systems), pertinent PFSH (1 element) This case: CC (eye injury), 4 HPI (OS, decreased VA, pain, 1 day), 2 ROS (eye, skin), 1 PFSH (fight)Detailed exam: at least 9 elementsThis case: VA, fields, motility, conjunctiva, adnexa, cornea, anterior chamber, iris and pupil, lensLow complexity decision-making:limited diagnoses, minimal data reviewed, low riskThis case: at least low complexityAnswer: 99203

  14. A 75-year-old established patient who is a contact lens-wearing aphake impaired by a stroke comes into the office to have the contact lens technician remove and clean his lenses, as the assistant does each month. The optometrist takes a brief look at the new lenses with the slit lamp.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  15. Established Patients Require Only 2 of 3 LevelsCode History Exam Decision Making99211 physical supervision only none none99212 problem focused problem focused straightforward99213 expanded problem expanded problem low complexity focused focused99214 detailed detailed moderate complexity99215 comprehensive comprehensive high complexity

  16. Problem-focused history: CC, brief HPI (1-3 elements)This case: CC (CL), 1 HPI (monthly exchange)Problem focused exam: 1 to 5 elementsThis case: corneaStraightforward decision-making:minimal diagnoses, minimal data reviewed, minimal riskThis case: straightforwardAnswer: 99211

  17. A 60-year-old patient last seen 3 months ago complains of the onset of constant diplopia the previous day. Acuities are reduced but unchanged, pupils and adnexa are unremarkable, but cover test reveals a superior oblique palsy of the right eye. ROS reveals a 40-year history of insulin dependent diabetes, with mild retinopathy. He takes several medications and is not alert. He also suffers from hypertension. Fields and tonometry are not reliable due to poor patient cooperation during testing. Slit lamp evaluation reveals dry eye and cataracts, and dilated fundus examination shows mild diabetic retinopathy and normal optic nerves. The patient is referred for a neurological workup to determine the cause of the 4th nerve palsy.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  18. Established Patients Require Only 2 of 3 LevelsCode History Exam Decision Making99211 physical supervision only none none 99212 problem focused problem focused straightforward99213 expanded problem expanded problem low complexity focused focused99214 detailed detailed moderate complexity99215 comprehensive comprehensive high complexity

  19. Detailed history: CC, extended HPI (3 chronic), extended ROS (2-9), pertinent PFSH (1)This case: CC (diplopia), 3 HPI (diabetes, arthritis, hypertension), 3 ROS (eye, endocrine, cardiovascular), 1 PFSH (diabetes)Detailed exam: at least 9 elementsThis case: VAs, pupils, adnexa, cover test, slit lamp (cornea, lens, iris and pupil), IOPs, fields, DFE (retina, nerve)Moderate complexity decision-making: multiple options, moderate data reviewed, moderate risk This case: moderate complexityAnswer: 99214

  20. A 73-year-old female current patient is brought to the office by a friend, who reports that she experienced a “blackout” of her vision about an hour earlier. The patient seems well oriented and reports that her field of vision has returned. Her history is unchanged since the last eye examination. Visual acuity, motility, and pupils are normal, and the adnexa is unremarkable. However, by confrontation field testing a homonymous hemianopsia is found. The patient is immediately referred to her primary care physician for an MRI.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  21. Established Patients Require Only 2 of 3 LevelsCode History Exam Decision Making99211 physical supervision only none none 99212 problem focused problem focused straightforward99213 expanded problem expanded problem low complexity focused focused99214 detailed detailed moderate complexity99215 comprehensive comprehensive high complexity

  22. Expanded problem-focused history: CC, brief HPI (1-3 elements), pertinent ROS (1 system) This case: CC (field loss), 3 HPI (OU, 1 hour, OK now), 2 ROS (eye, neurological)Expanded problem-focused exam: at least 6 elementsThis case: VA, fields, motility, adnexa, pupilsLow complexity decision-making:limited diagnoses, minimal data reviewed, low riskThis case: at least low complexityAnswer: 99213

  23. A 50-year-old patient previously diagnosed with dry eye returns with the complaint that her eyes water a lot and have been “much worse” for the past month. Visual acuity is 20/20, there is inferior corneal staining with fluorescein (but not rose bengal), and her puncta are observed to be patent. She has been using artificial tears prn, and a sterile ointment is prescribed, to be placed in the lower cul-de-sac at bedtime for the next two weeks, after which she is scheduled to return for re-evaluation.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  24. Established Patients Require Only 2 of 3 LevelsCode History Exam Decision Making99211 physical supervision only none none 99212 problem focused problem focused straightforward99213 expanded problem expanded problem low complexity focused focused99214 detailed detailed moderate complexity99215 comprehensive comprehensive high complexity

  25. Problem-focused history: CC, brief HPI (1-3 elements)This case: CC (watering), 3 HPI (OU, 1 month, getting worse)Problem focused exam: 1-5 elementsThis case: VA, conjunctiva, adnexa (lids), corneaStraightforward decision-making:minimal diagnoses, minimal data reviewed, minimal riskThis case: straightforwardAnswer: 99212

  26. An alert but dependant (due to vision) 80-year-old new patient with primary open-angle glaucoma and wet ARMD (like his mother) that has caused central vision loss OS (20/200) and degenerative change OD (20/25) seeks consultation because his IOPs are poorly controlled. Pupils, motilities, and adnexa are unremarkable, and cover test reveals no deviation. Refraction does not improve VAs at distance or near. Slit lamp examination reveals dry eye, open angles, and mild cataract OU. Pressures are 18 and 19 mmHg, and confrontation fields indicate significant field loss OU. Blood pressure is 180/95 mmHg. Dilated fundus evaluation indicates there is central macular loss OS and degeneration surrounding the macula OD, and mild crossing changes indicative of hypertensive retinopathy. The optometrist prescribes tears and ointment for the dry eye, changes the drops being used to treat the glaucoma, and schedules the patient to return for automated visual fields and ocular coherence tomography. New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  27. New Patients Require All 3 LevelsCode History Exam Decision Making99201 Problem focused Problem focused Straightforward99202 Expanded problem focused Expanded problem focused Straightforward99203 Detailed Detailed Low complexity99204 Comprehensive Comprehensive Moderate complexity99205 Comprehensive Comprehensive High complexity

  28. Comprehensive history: CC, extended HPI (4 elements) complete ROS (10), complete PFSH (3)This case: CC (IOP), HPI (>3 chronic conditions: hypertension, ARMD, POAG, dry eye), ROS (hypertension), PFSH (ARMD and glaucoma, mother had ARMD, limited autonomy)Comprehensive exam: 12 elementsThis case: all 12, orientation to time, place, person (alert)High complexity decision-making: extensive options, extensive data, high riskThis case: high complexityAnswer: 99205

  29. An alert 75-year-old smokerwith diabetes for 30 years (like his twin) returns for examination complaining of decreased vision OU. Corrected visual acuities are 20/40 OD and 20/60 OS, improved to 20/30 OU at near. There is unilateral miotic pupil and ptosis OD, no ocular restrictions, and ortho cover test. Corneas display pronounced arcus, angles are 1:1/4, and there are 3+ lens cortical changes OU. Tonometry is normal, but confrontation fields indicate there is temporal field loss OS. Dilated fundus evaluation reveals severe non-proliferative diabetic retinopathy, with presumed macular edema OD and significant optic nerve pallor OS. The patient is immediately referred to a retinal specialist for fluorescein angiography and focal laser therapy of the retinopathy.New patients 99201 99202 99203 99204 99205Established patients 99211 99212 99213 99214 99215

  30. Established Patients Require Only 2 of 3 LevelsCode History Exam Decision Making99211 physical supervision only none none 99212 problem focused problem focused straightforward99213 expanded problem expanded problem low complexity focused focused99214 detailed detailed moderate complexity99215 comprehensive comprehensive highcomplexity

  31. Comprehensive history: CC, extended HPI (4 elements) complete ROS (10), complete PFSH (3)This case: CC (VA), 4 HPI (OU, OS>OD, improved with glasses, at near), ROS (diabetes), 3 PFSH (diabetes, twin also diabetic, smoker)Comprehensive exam: 12 elementsThis case: all 12, orientation to time, place, person (alert)High complexity decision-making: extensive options, extensive data reviewed, high risk This case: probably moderate complexityAnswer: 99215

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