Hello!
I am going back and forth with a provider. I requested them to reduce their LOS because I do not feel a 99214 is appropriate. I am trying to explain that the work up for the I&D is bundled into that procedure code and should not be used towards the complexity of the E/M. Idk, maybe I'm wrong. Would appreciate opinions of other coders. Please see below.
Patient presents with
Lump in Skin
Patient has complaints of lump under right arm. It has been there for 3 days. Sometimes it hurts but denies discharge. Denies fevers/chills/night sweats.
DM2:
- taking Lantus 10 units in the morning and 10 units at night
- taking Metformin 1 tab in the morning
- checking sugars in the day, today it was 210 in the morning, before breakfast
- usually runs in the 200s
Review of Systems
Constitutional: Negative for chills and fever.
Gastrointestinal: Negative for nausea and vomiting.
Vitals
Vitals:
07/12/19 0954
BP: 155/82
BP Site: Right Arm
BP Position: Sitting
BP Cuff Size: Regular Adult
Pulse: 82
Resp: 15
Temp: 97.9 °F (36.6 °C)
TempSrc: Tympanic
SpO2: 96%
Weight: 206 lb 9.6 oz (93.7 kg)
Physical Exam
Constitutional: No distress.
HENT:
Head: Normocephalic and atraumatic.
Eyes: EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales.
Abdominal: Soft.
Lymphadenopathy:
He has no cervical adenopathy.
Skin: Skin is warm. He is not diaphoretic.
Abscess in right axilla with surrounding erythema extending to mid-arm
Psychiatric: He has a normal mood and affect. His behavior is normal.
Vitals reviewed.
Data:
BP Readings from Last 3 Encounters:
07/12/19 155/82
07/11/19 131/76
06/24/19 108/73
Wt Readings from Last 3 Encounters:
07/12/19 206 lb 9.6 oz (93.7 kg)
07/11/19 208 lb 8.9 oz (94.6 kg)
06/24/19 205 lb 9.6 oz (93.3 kg)
Assessment and Plan
L02.91 Abscess (primary encounter diagnosis), successfully I&D'ed in office, concern for surrounding cellulitis
- instructed to go to the ED if worsening signs of infection or bleeding that cannot be stopped
- instructed to replace bandage twice daily
- RTC on Monday for nurse visit for wound check, possible repacking
Plan : • IBUPROFEN 800 MG TABLET - Take 1 Tab by mouth
3 (three) times daily as needed for pain
PRE-OP DIAGNOSIS: Abscess
POST-OP DIAGNOSIS: Same
PROCEDURE: incision and drainage of abscess
PROCEDURE:
Appropriate consent was obtained. A timeout protocol was performed prior to initiating the procedure. The area was prepped and draped in the usual, sterile manner. The site was anesthetized with 2 cc of 1% lidocaine with epinephrine. A linear incision along the local skin lines was made using a #11 scalpel. Copious amount of purulent material was expressed with manual expression. Bleeding was minimal (~2-3 mL). Wound was cleansed with sterile saline and packed with a sterile packing strip. Wound was covered with a bandage.
Followup: The patient tolerated the procedure well without complications. Standard post-procedure care was explained and return precautions given.
L03.111 Cellulitis of right axilla
Plan: • AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125
MG TABLET - Take 1 Tab by mouth 2 (two) times daily for 10 days
• DOXYCYCLINE HYCLATE 100 MG TABLET - Take 1
Tab by mouth 2 (two) times daily for 10 days
E11.65 Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin (HCC-CMS) (primary encounter diagnosis)
Plan : • GLUCOSE, BLOOD, HEMOCUE (POCT)
- instructed to increase PM Lantus by 2 units every 2-3 days for goal AM glucose of 100-120
- increase Metformin to 1000 mg BID
Diabetes Mellitus:
Changes Today Insulin dose increased and Oral medications increased
Reviewed: Appropriate lifestyle modifications and Control of other comorbid conditions
I am going back and forth with a provider. I requested them to reduce their LOS because I do not feel a 99214 is appropriate. I am trying to explain that the work up for the I&D is bundled into that procedure code and should not be used towards the complexity of the E/M. Idk, maybe I'm wrong. Would appreciate opinions of other coders. Please see below.
Patient presents with
Lump in Skin
Patient has complaints of lump under right arm. It has been there for 3 days. Sometimes it hurts but denies discharge. Denies fevers/chills/night sweats.
DM2:
- taking Lantus 10 units in the morning and 10 units at night
- taking Metformin 1 tab in the morning
- checking sugars in the day, today it was 210 in the morning, before breakfast
- usually runs in the 200s
Review of Systems
Constitutional: Negative for chills and fever.
Gastrointestinal: Negative for nausea and vomiting.
Vitals
Vitals:
07/12/19 0954
BP: 155/82
BP Site: Right Arm
BP Position: Sitting
BP Cuff Size: Regular Adult
Pulse: 82
Resp: 15
Temp: 97.9 °F (36.6 °C)
TempSrc: Tympanic
SpO2: 96%
Weight: 206 lb 9.6 oz (93.7 kg)
Physical Exam
Constitutional: No distress.
HENT:
Head: Normocephalic and atraumatic.
Eyes: EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales.
Abdominal: Soft.
Lymphadenopathy:
He has no cervical adenopathy.
Skin: Skin is warm. He is not diaphoretic.
Abscess in right axilla with surrounding erythema extending to mid-arm
Psychiatric: He has a normal mood and affect. His behavior is normal.
Vitals reviewed.
Data:
BP Readings from Last 3 Encounters:
07/12/19 155/82
07/11/19 131/76
06/24/19 108/73
Wt Readings from Last 3 Encounters:
07/12/19 206 lb 9.6 oz (93.7 kg)
07/11/19 208 lb 8.9 oz (94.6 kg)
06/24/19 205 lb 9.6 oz (93.3 kg)
Assessment and Plan
L02.91 Abscess (primary encounter diagnosis), successfully I&D'ed in office, concern for surrounding cellulitis
- instructed to go to the ED if worsening signs of infection or bleeding that cannot be stopped
- instructed to replace bandage twice daily
- RTC on Monday for nurse visit for wound check, possible repacking
Plan : • IBUPROFEN 800 MG TABLET - Take 1 Tab by mouth
3 (three) times daily as needed for pain
PRE-OP DIAGNOSIS: Abscess
POST-OP DIAGNOSIS: Same
PROCEDURE: incision and drainage of abscess
PROCEDURE:
Appropriate consent was obtained. A timeout protocol was performed prior to initiating the procedure. The area was prepped and draped in the usual, sterile manner. The site was anesthetized with 2 cc of 1% lidocaine with epinephrine. A linear incision along the local skin lines was made using a #11 scalpel. Copious amount of purulent material was expressed with manual expression. Bleeding was minimal (~2-3 mL). Wound was cleansed with sterile saline and packed with a sterile packing strip. Wound was covered with a bandage.
Followup: The patient tolerated the procedure well without complications. Standard post-procedure care was explained and return precautions given.
L03.111 Cellulitis of right axilla
Plan: • AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125
MG TABLET - Take 1 Tab by mouth 2 (two) times daily for 10 days
• DOXYCYCLINE HYCLATE 100 MG TABLET - Take 1
Tab by mouth 2 (two) times daily for 10 days
E11.65 Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin (HCC-CMS) (primary encounter diagnosis)
Plan : • GLUCOSE, BLOOD, HEMOCUE (POCT)
- instructed to increase PM Lantus by 2 units every 2-3 days for goal AM glucose of 100-120
- increase Metformin to 1000 mg BID
Diabetes Mellitus:
Changes Today Insulin dose increased and Oral medications increased
Reviewed: Appropriate lifestyle modifications and Control of other comorbid conditions