Wiki Case #12 Winner, Answer Key, & Rationale

alex.mckinley@aapc.com

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Tracey W. won case #12. 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
 
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Tracey W. won case #12. 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
The BMI was not documented that I can see. The guidelines specify that the BMI must be documented to code it. I disagree with the level 4 I counted only enough for a level 3, I find 6 points of exam not 8.
 
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I am curious why the family history of colon cancer was not also coded in this example?
 
The BMI is documented in the vitals portion of the physical exam wt: 298 (BMI 44).

Thank you! I actually looked every where for it when I coded it. I just did not see it. I did see the weight and found the 2981bs to be humorous as I at first thought it was saying 2,981 pounds! and missed the BMI completely. Oh well next case!
 
Quite honestly, I did not code the UA as "with microscopy" because the note said "it WILL be done". Not that it was... So I coded it based on what was actually done and documented, NOT what the provider said he will do... eventually.

Also, The documentation says "the peripheral neuropathy he is experiencing as a result of the diabetes". NOT Polyneuropathy...
So I coded this as the secondary Peripheral neuropathy...

Oh well, I suppose...
 
Case #12

I agree that you cannot bill what will be done but what was done. My experience has been you do not bill V codes on a visit with a medical diagnosis. Carriers usually will not pay if there are regular medical dx codes with v codes.
Please explain why there is no 25 modifier.

Why is the HTN 401.9 when the notes state it is benign.

I love this coding challenge. :D Thanks.
 
I agree that you cannot bill what will be done but what was done. My experience has been you do not bill V codes on a visit with a medical diagnosis. Carriers usually will not pay if there are regular medical dx codes with v codes.
Please explain why there is no 25 modifier.

Why is the HTN 401.9 when the notes state it is benign.

I love this coding challenge. :D Thanks.

V codes can be on claims with medical dx codes. The statement "Carriers usually will not pay if there are regular medical dx codes with v codes." Is not true. There is absolutely nothing wrong with combining them and and the claim will not deny as a result.
 
V codes can be on claims with medical dx codes. The statement "Carriers usually will not pay if there are regular medical dx codes with v codes." Is not true. There is absolutely nothing wrong with combining them and and the claim will not deny as a result.

I did say MY experience. Thanks for the kind comments.
 
The BMI was not documented that I can see. The guidelines specify that the BMI must be documented to code it. I disagree with the level 4 I counted only enough for a level 3, I find 6 points of exam not 8.

The BMI is shown in parenthesis after the wt.
 
I was curious why daily aspirin use (V5866) and positive for colon cancer with his father and breast cancer in one sister was not coded.
 
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
 
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