Case # 12 clinical added for Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.
See below for the answer key and rationale.
ANSWER KEY
CPT: 99214, 81000 or 81001
CPT Modifiers: none
ICD-9: 250.60, 357.2, 715.36, 401.1, 305.1, 278.01, V85.41, V58.67
RATIONALE
CPT: 99214, 81000 or 81001
The provider performed a Detailed history (status of three chronic conditions, extended ROS, complete PFSH), Comprehensive exam (8 systems), moderate MDM (one new condition with additional workup, 4 established problems; 1 data point (labs), and moderate MDM for treating two or more stable chronic conditions. Although it indicates the patient is new to the provider, he has been seen in the practice within the last two years.
Steps to lookup: Established/Patient/Office Visit; Urinalysis. The note indicates that microscopy will be performed in addition to the UA dipstick.
ICD-9-CM 250.60, 357.2, 715.36, 401.1, 305.1, 278.01, V85.41, V58.67
Steps to look up: Diabetes, diabetic/with/peripheral autonomic neuropathy; Osteoarthrosis/localized/knee (fifth digit); Hypertension/benign (column); Abuse/drugs, nondependent/tobacco; Obesity/morbid; BMI/adult/40.0-44.9; Long-term drug use/insulin.
Hint: This 49-year-old male presents to me as a new patient. He has seen Dr. J (who is no longer in this practice) 2 years ago . He is a Type II diabetic who is being followed by an endocrinologist. It will be important to have lay terms and your index handy for this one.
Reminder: the 3 year rule for new patient. However, Visits with patients who do not transfer care to their primary physician's change of practice and are seen by another family physician in the original group within the three-year time frame are reported as established patient encounters. In this instance, the patient’s status is determined by the group identification, the time frame since the last encounter and the specialty of the physician providing care.
http://www.aafp.org/fpm/2003/0900/p33.html
CASE # 12
This 49-year-old male presents to me as a new patient. He has seen Dr. J (who is no longer in this practice) 2 years ago. He is a Type II diabetic who is being followed by an endocrinologist. He is under good control and is very diligent with managing his sugars. He smokes approximately 1 1/2 packs of filtered menthol cigarettes per day. He has no interest in quitting. He has a history of high blood pressure which is benign and under good control with a Beta Blocker. He does not exercise and feels comfortable at his current weight. He does not like the side effects of the medication; light headedness and occasional nausea. He wonders if there are other options of medications. He also complains of numbness in his fingers on occasion. On further questioning he also has some loss of sensation in his feet. Lastly, he complains of knee pain. He does not know when it started but has been a problem for several months. He did play football in high school and he knees have always been "creeky". There was no specific injury he could remember.
Medications:
Insulin 201 50r
Beta blocker
ASA one baby per day
Mobic qd
Motrin pm
HISTORY:
He lives with his wife of 25 years and is employed as a mechanic. He has had no surgeries other than a tonsillectomy at age 10. His family history is positive for colon cancer with his father and breast cancer in one sister. Both are alive. He has no known allergies.
ROS:
No fevers, fatigue or headaches
No hearing loss or changes in vision
No SOB
Denies chest pain or tightness
Denies vomiting or diarrhea
Some problems with impotence
EXAM:
Vitals: BP 130/90; pulse 72; height 5'9" wt: 2981bs (BMI 44)
Well nourished white male in no acute distress
HEENT - normal
No cough or wheeze
Heart - RRR
Abdomen soft, liver and spleen WNL
Descended testicles circumscribed male
Knee pain, bilateral worse with cold weather
UA by dip stick was done today which had preliminary normal results, micro will be performed.
I have counseled him on quitting smoking and to consider an exercise program. His obesity is an issue for his hypertension and his diabetes. Although his diabetes appears to be well controlled at this point (according to his logs) I am concerned about the peripheral neuropathy he is experiencing as a result of the diabetes and have asked the patient to see his endocrinologist at his earliest convenience to allow him to manage this symptom. He has a localized osteoarthritis in his knees. I like him to consult with Dr. to see if there is anything that acutely needs to be addressed. Otherwise, I have instructed him to continue on his current medication regime.
Dx:
HTN
Diabetes
Osteoarthritis
Morbid Obesity
Thanks.