This particular patient presented with wheezing, decreased air movement in the LLL and a left acute otitis media. Sats were 86%. After three Xopenex 1.25 mg nebs and 60 mg of Prednisone, they were up to 93%. His RR was down, his pulse rate was down and fever down from 103 to 99.9 with Tylenol and Motrin. His CXR did show a lobar pneumonia, and he was diagnosed with pneumonia, asthma exacerbation and otitis media. Given the amount of time the patient required, my note was not as thorough as it could have been. It was difficult to not charge a 99214, but technically it wouldn't meet the E & M coding requirements.
Not sure which guidelines you are using (1995 vs 1997), but I know that with the 1995 guidelines there are 7 "dimensions" of an OV. These are:
1. history
2. physical examination
3. medical decision making
4. counseling
5. coordination of care
6. nature of the presenting problem
7. time
Typically, coders/physicians use the first 3 dimensions to determine the level of a visit. However, the last 3 can override what would be determined by analysis of the typical 3 (history, pe, decision making). For your patient, exacerbation(depending on the severity of the exacerbation) could have made it an automatic 99214. It sounds to me like that patient was in pretty bad shape, you might have even been able to charge a 99215.
