Coding and Billing Worksheet Essay

Coding and Billing Worksheet: 10 Year-Old Joey Doe

1. Determine which E & M code to use to bill for this exam. Use the coding guide to answer the following questions.
2. How many elements of the HPI are addressed? (hint: POLDCARTS)

The number of elements of the HPI addressed is seven (7). These include previous history, the timing of symptoms, aggravating factors, duration, symptom characteristics, onset of symptoms, and relieving factors (Health Information Guide, n.d.).

2. How many elements (systems) of the ROS are addressed?

The number of elements or systems of the ROS addressed is five (5). These are eyes (itchy/ watery), nose and throat (sneezing, denies difficulty in swallowing), integumentary (hives, rashes), allergic/ immunologic (denies swelling of the face), and respiratory (denies difficulty in breathing or excessive coughing). Coding and Billing Worksheet Essay.

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3. How many History areas are covered – PMH, Medications, family, social history? (PFSH)

The number of history areas covered is six (6). These are medication history, past medical history, family history, social history, surgical history, and allergy history (allergic to grass).

4. How many organ systems were examined? (PE)

The number of organ systems examined was six (6). These were constitutional, eyes, HEENT, pulmonary, cardiovascular, and the skin (integumentary).

5. Was the HPI considered a brief history or an extended history?

The HPI was considered an extended history because it had more than four (4) elements.

6. Was the review of systems considered problem pertinent, extended, or complete?

The review of systems was considered extended. This is because five systems were reviewed.

7. Was the PFSH pertinent or complete?

The PFSH was complete because all 3 history areas were reported.

8. Was the examination problem-focused, expanded problem-focused, detailed, or comprehensive?

The examination was detailed because of the inclusion of the cardiovascular system.

1. When you have your answers– Put an “X” in the appropriate boxes of the “Table of E & M Code Requirements” to determine your billing code. Whichever column has the most “Xs” will be your code. Coding and Billing Worksheet Essay.

TABLE OF E & M CODE REQUIREMENTS – ESTABLISHED PATIENT

1. Which column are the majority of your “Xs” placed?

This is your E & M code.

The majority of the “Xs” are placed in the column with the E&M code of 99214. According to the current procedural terminology or CPT, the indication for this E&M code is for an office or any other outpatient visit for the assessment and treatment of a patent that is not new. It is correct if at least two of the following are present during the history and physical examination of the outpatient:

1. A detailed history of the patient
2. A detailed physical examination of the patient, and

• Decision making of moderate complexity

This is therefore a level 4 visit of an established patient (Medical Billing, n.d.). Coding and Billing Worksheet Essay.

References

Health Information Guide (n.d.). POLDCARTS. http://www.healthcare-information-guide.com/support-files/poldcarts_table.pdf

Medical Billing (n.d.). Medical billing and coding – procedure code, ICD code. http://www.whatismedicalinsurancebilling.org/2010/07/medical-billing-cpt-99214-when-and-how.html

Week 2 Assignment Instructions

NRP/531: Advanced Health Assessment I

Wk 2 Coding & Billing Worksheet

• This week you gained insight regarding the requirements needed to determine billing codes. Now it is time to apply what you have learned.
• Utilize the Coding Guide (see attached) and Superbill (see attached) example as a reference to complete the Coding & Billing Worksheet (see attached).
• Complete the Coding & Billing Worksheet (see attached). Coding and Billing Worksheet Essay.
• A minimum of two scholarly peer reviewed references required.
• APA format only.

CHIEF COMPLAINT: Allergies

S: HISTORY OF PRESENT ILLNESS: Joey is a 10-year-old male who presents today with his mother, who is deemed a reliable historian, for medication refills and to discuss his allergies and asthma. She states he has allergy symptoms in the spring and fall, which will make his asthma symptoms worse. He is also allergic to grass. Reports allergy symptoms for 8 years, and they have been about the same for the last several years. Symptoms described as itchy/watery eyes, sneezing, and occasionally hives when in contact with grass. Will also occasionally get rashes. Denies swelling to face or difficulty swallowing or breathing.

In addition to those symptoms, he was diagnosed with asthma since early childhood. Mother reports his asthma is well controlled with daily Singulair and an Albuterol inhaler as needed. Reports Albuterol use = 2-3 x week when his allergies are flared up. Mother states she is adept at treating her son’s asthma exacerbations at home and has not needed to go to the ER for years. Denies recurrent illnesses or excessive coughing.

SOCIAL HISTORY: Pt lives with both parents in an apartment with no pets. His family moved to Arizona in 2008 from Florida in the hopes that the desert environment would alleviate his asthma symptoms. Non-smoking household. Normal developmental milestones, no behavioral issues, and up to date on vaccines.

FAMILY HISTORY: Mother with asthma and allergic rhinitis. No siblings.

PAST MEDICAL HISTORY: Asthma, Allergies, Eczema. NKDA.

MEDICATIONS: Singulair 10mg QD and Albuterol inhaler 1-2 puffs q 4 hours prn wheezing.

SURGICAL HISTORY: Tonsillectomy and adenoidectomy in 20YY at 2 years old. Coding and Billing Worksheet Essay.

O:  PHYSICAL EXAMINATION:

GENERAL: Well-nourished young male who appears stated age without distress. HEENT-Normocephalic. PERRLA. Conjunctiva clear. Nasal turbinates and buccal mucosa pink and moist. No polyps or discharge noted in nasal passages. Oral cavity with good dentition. Pharynx without erythema or edema. TM’s pearly grey with cone of light noted bilaterally and bony landmarks visible. Neck supple with no lymphadenopathy or thyromegaly. PULM– Clear to auscultation bilaterally with no adventitious breath sounds. CARDIO-RRR. S1,S2 sounds with no murmurs, heaves, lifts, or thrills. DERM: No rashes. Good turgor. Coding and Billing Worksheet Essay.

ASSESSMENT (A)/PLAN (P):

1. Asthma – Continue Singulair 10mg QD and Albuterol inhaler as needed. Will refill today.

Asthma action plan discussed with mother

2. Allergies – Discussed avoidance measures. Use OTC Claritin 10mg QD and/or Benadryl 25mg q 4 hours as needed for symptom relief
3. Eczema – Can also use OTC Hydrocortisone cream 1% topically as needed
4. Follow up appointment in 6 months

1. Determine which E & M code to use to bill for this exam. Use the coding guide to answer the following questions.

1. How many elements of the HPI are addressed? (hint: POLDCARTS) __________
2. How many elements (systems) of the ROS are addressed?      ___________
3. How many History areas are covered – PMH, Medications, family, social history? (PFSH) _____
4. How many organ systems were examined? (PE) _______
5. Was the HPI considered a brief history or an extended history? ________
6. Was the review of systems considered problem pertinent, extended, or complete? _______
7. Was the PFSH pertinent or complete? _________
8. Was the examination problem-focused, expanded problem-focused, detailed, or comprehensive?

When you have your answers– Put an “X” in the appropriate boxes of the “Table of E & M Code Requirements” to determine your billing code. Whichever column has the most “Xs” will be your code.

TABLE OF E & M CODE REQUIREMENTS – ESTABLISHED PATIENT

1. Which column are the majority of your “Xs” placed?

This is your E & M code. Coding and Billing Worksheet Essay.