Wiki Audit level

Messages
13
Location
Pollock Pines, CA
Best answers
0
I am questioning the coding of the attached note. Can someone please look at the note and give me your opinion? I feel there may be an element of medical necessity.

Thanks!

Progress Notes

Chief Complaint
Patient presents with
• Cough
x 1 week

HPI:

is here today with his father due to cough he has had for about 1 week. He said no congestion or runny nose. He has no history of asthma. He does not use tobacco. He has had no significant fever. He is drinking and eating well. He is not having difficulty sleeping. No difficulty breathing. Is able to play basketball without much difficulty or cough.


PHE:
BP 104/64 (SITE: right arm, Orthostatic Position: sitting, Cuff Size: regular) | Temp 36.7 °C (98.1 °F) (Temporal) | Ht 1.689 m (5' 6.5") | Wt 68.3 kg (150 lb 8 oz) | BMI 23.93 kg/m²

Alert no acute distress. Sclera clear he has no eye discharge. Tympanic membranes clear bilaterally. Oropharynx clear moist his membranes. Nose is clear discharge. Chest is clear and unlabored throughout without prolonged expiration or wheezing. Is regular rate and rhythm. He has no significant cervical lymphadenopathy.

Impression/Plan:
ICD-10-CM
1. Cough R05


Father was reassured. Asked him to drink plenty of fluids and call if symptoms worsens at all especially if he develops fever. I suspect this is likely viral in nature and just needs some more time. Did not see reason to put him on antibiotics at this time without any significant nasal symptoms.
 
Looks like a 99212 or 99202 to me. I don't see the MDM as Low on this one, unless you could argue that the Cold is a New Problem w/o add. work up. However, since the provider is not really doing much of a work-up, I would consider moving this problem into the Self-Limited/Minor problem category.
 
Another way at looking at this (and perhaps remind the provider of), is that at the end of the day, everything boils down to medical necessity, and not points counting. Is the cough really that severe to bump it up to a Low complexity? The patient is not an infant (based on the Vital signs), or otherwise immune compromised. I do not see any severe commodities, or anything that would indicate that the patient is at higher risk of illness. I think sometimes we as coders and the providers lose sight of the reason for documentation and what truly supports an E/M level. Having been on both sides of the equation, I totally get it from a provider and a payer point of view, however that being said the main CMS E/M guidelines are still a good indicator (although vague at times) on where to put a condition when it comes to MDM. Don't forget that come 2021, we will get a revamped E/M set of guidelines that will change everything when it comes to E/M coding.

Hope this helps!
 
Top