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Auditing Progress Notes

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Newsletter 2016-06-14

Hello everyone! Hope you all are having a good summer. I'm very excited about a new educational seminar we will be offering in October entitled Pediatric Coding Strategies. Read down below for more information.

Auditing Notes

Today I'd like to audit a note together. As you all know, coding is very important to me. It is imperative that every encounter gets coded correctly; neither too high nor too low. One thing I do is go back and audit 99213s in our practice-both my notes and the other providers. I came across a note that I'd like to share with you:

CC: UTI/pregnancy check

HPI: Patient is 17yo female in juvenile detention facility. Has pain with urination. According to case worker has not had a menstrual period in over a month now.

PMH: Meds:

  • Fluticasone 1 spray each nostril once/day.
  • Zyrtec 10mg q day.
  • Albuterol sulfate HFA 2 puffs q 4 hours prn.
  • Asmanex 220mcg 1 puff every evening.


  • Dysuria (R30.0)


  • Urine pregnancy test: negative
  • UA: within normal limits
  • Encourage fluids
  • Follow-up prn

That's it. That's the whole note. No physical exam even documented. The provider billed a 99212 with the reasoning of "I didn't really do anything. Not even an exam." But let's take a look at this and see where we are at:

In history, we have a Chief Complaint, Medical History (medication list), and Social History (in detention facility). We have 4 elements of HPI (location=GU system, context=with urination, associated symptoms=no menstrual period, duration=over a month). We also have one Review of Systems (GU; no period in over a month). This is enough information for an Expanded Problem Focused History. Notice, however, that if we had one more review of systems, it would be enough history for a Detailed History. More about this later. . .

We have no Physical Exam. Now remember that Medical Decision Making is calculated from the Diagnosis/Management Options, Data Review, and Risk.

There are 2 ways to calculate Diagnosis and Management Options. The first is just see how many there are. We have 1 diagnosis and 2 management options (fluids, follow-up). So 2 points. Using the other method that we won't go into here, she either has a minor problem (worth 1 point), or a new problem that doesn't require further workup (3 points). In order to err on the conservative side, I will give credit for 2 points here. This is a Limited Diagnosis and Management Options.

Data Review has several points in this note. We get 1 point for ordering lab tests (UA and pregnancy test). We also get 2 points for "summarizing the history from someone other than the patient" (the case worker). That gives us 3 points for Data Review which is a Moderate Data Review.

Risk is straightforward: This seems to fall into the category of Acute rather than chronic problem. Most auditors would say this problem is an Acute Uncomplicated Illness. This gives us a Low Risk for this patient.

When these three factors are taken together, we have a Low Level of Decision Making. When you combine this with the level of History and Exam, we have fulfilled the requirements for a 99213! This should not have been coded as a 99212. Even though you may 'feel bad' because you didn't do any physical exam, this is a 99213 note and should be coded as such.

Now the Rest of the Story. . .

But let's look even further: I looked back at her chart. Her last visit was 3 months ago for asthma. What if we asked the simple question; "how are your allergies and asthma doing?" Then added in the following to her HPI: "Also has asthma and allergies. Well controlled on current medications." And add to her Review of Systems: "Denies allergy or asthma symptoms". Now we have a Detailed History.

Now we add both of these diagnoses into her assessments. In our treatment plans we indicate for her to continue on the current allergy and asthma medications. This now boosts our level of Risk to Moderate (2 stable chronic problems). It also boosts our Diagnosis and Management options up to Multiple (or extensive if you add in the diagnosis of dysmenorrhea, but we'll stick with Multiple for now).

When added all together now we have enough information for a 99214! Even without any Physical Exam! This brings up 2 coding points:

  • 1.If you think the note is a 99212, check to make sure because it might be a 99213.
  • 2.If appropriate, ask about their problem list and med list and document these items.

That's all the tips for now. But don't leave yet:

Pediatric Coding Strategies conference

I'm very excited to introduce our first ever Coding conference specific for pediatricians! I will have more information in the following few months, but here are some of the details.

The conference will be held Saturday, October 22nd in Atlanta, Georgia. Sign up online on our website. The DVD course will be available as well and will ship around 10 days after the conference. To pre-order click here.

This course is an advanced-level course intended for audiences that have already taken and internalized the concepts in our Coding Growth Strategies course. Here are a few of the things we will be covering:

  • Charting Pitfalls (the 5-8 things I look for when auditing my own notes. Like we discussed above, what things can I look for that will appropriately increase the level of service)
  • The not-normal newborn (when should you code higher than typical newborn codes)
  • Templates (dozens of templates will be provided to the participants. These are the actual templates I use in my practice. You will also receive pdf files so you can print these yourself. Also the Word documents will be provided so you can easily edit to suit your own practice)
  • Common level 5 patients in pediatrics and how to document them quickly and easily
  • Why almost every sick infant should be appropriately coded a 99214
  • Maximizing reimbursement for Health Maintenance Visits
  • Strategies to increase revenue during the slow Summer slump
  • Utilizing nurses to improve coding and documentation
  • Plus a lot more!

If you are a pediatrician this could be one of the most financially beneficial things you can do for your practice. We will learn to maximize our coding, reimbursement, and fill all of our appointment slots every day. In the next month, I will be sending out a letter to all of our pediatric clients that will discuss in detail everything that we will cover in this conference. Of course I will always offer my money-back guarantee but you can be assured that the information we will cover will be the most helpful thing to your practice since you attended your first Coding Growth Strategies seminar.

That's all for today. Good luck with your practices.

Paul Firth MD

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