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Code A Round E&M CEU

PERRAULT

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Location
Spring Hill , FL
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I am stuck on this senerio for the E&M Code A Round. I have entered (correctly) 99203, 99406, 724.4 722.52 and several others that are incorrect. I can't figure out what they are looking for. Is there a specific ICD-9 for: pain, tingling and weakness? I don't know what I am missing, maybe looking at it too long. Would appreciate any help I can get. Thank you :confused: Here is the senerio:

"Dear Dr.

It was my pleasure meeting with PATIENT today in initial neurosurgical consultation for his left leg pain. As you well remember, he is an extremely pleasant PATIENT who works for A COMPANY and developed left leg pain in 2005; there was no particular event or cause that he can attribute to this. It has been slowly progressive in severity over the past few months. It has remained in the same location throughout the duration of his symptoms. He has tried various conservative measures including medications, NSAIDs, physical therapy, various other activities - none of these provided any lasting benefit.

He states that his pain radiates down the buttock, the posterior thigh, the posterior calf, and radiates over the top of the foot toward the great toe, but involves the top and bottom of the foot and all the toes -he cannot really define that further. He experiences discomfort in his buttocks, "like I am sitting on a nail". He denies any right leg symptoms, denies any bowel or bladder problems. In addition to the pain, he experiences a tingling and a burning sensation; he feels general weakness in the left leg as well. He is able to drive a car and do activities of daily living. The severity is a 7/10 on average, but can go up to a 10/10. The best position for him is sitting, and the worst position is standing. It is exacerbated by coughing. There is no particular other context to the symptoms. He denies fevers, chills, nausea, vomiting, weight loss or weight gain. He has not had any prior surgeries to the low back. He has not required any EMG studies in the past. There is no litigation pending.


Past Medical History:
1. Hypertension.
2. BPH-"cleared up".
3. Reflux disease.
4. Headaches.
5. Hypercholesterolemia.
6. Kidney surgery for a benign tumor in October 2004 - he had a lot of bleeding with this, and the bleeding was attributed to his use of aspirin. He required blood transfusions at that time.

7. Status post appendectomy (gangrenous). Again he had blood loss and required transfusions. Since then he has stopped the aspirin.
8. In general, he denies easy bruising or easy bleeding, and did not have any anesthesia reactions.


Medications: 1. Protonix40-mg. 2. Gemfibrozil 600-mg q. day. 3. Norvasc 10-mg q. day. 4. HCTZ 25-mg q. day. 5. Diovan 160-mg q. day. 6. Tramadol 50-mg p.m.-he takes approximately 4 tablets in a week. 7. Vitamin C and Vitamin E.

Allergies: NKDA.

Social History: He is married and has a healthy child. He works AS AN EMPLOYEE OF A COMPANY, which involves a lot of driving and attending meetings. He previously was IN MILITARY SERVICE and describes himself previously as a "physical fitness nut". He smokes approximately 1 pack per 1-2 weeks, and he has done so for about the past forty-five to fifty years. He has not had any since Friday. He drinks 2-3 beers per week, he denies excessive use previously. He denies HIV or hepatitis, but does have the risk of multiple transfusions.


Family History: heart disease IN PARENTS; SIBLING and OTHER RELATIVE both had breast cancer; SIBLING has diabetes; multiple family members have hypertension.


Review Of Systems: Except as indicated above, all other systems negative - the ROS form was completed by the patient, reviewed by me personally, and filed in the patient chart.


Physical Exam: He is a male, well-developed, well-nourished, no acute distress, pleasant and cooperative for the entire exam. Ht: DOCUMENTED Wt: DOCUMENTED, and BP: NORMAL. He is an excellent historian and has an appropriate affect, a bit stoic. His spine is in good alignment with no stepoffs. He has no spinous process tenderness, no sciatic notch tenderness, mild left SI joint vs. paravertebral tenderness. He has mild paravertebral spasm on the left. Scapulae are of equal height with no splaying and no hump. His extremities are atraumatic with no contractures. No amputations. No A-V insufficiency and no edema. He is very well kept, and his skin integrity is good. His gait is overall normal, but with becomes antalgic with the various testing we did today. He is willing to try toe and heel walking, but had difficulty maintaining walking on the toes. He is able to do the alternating deep knee bends. His strength is 5/5 bilaterally both proximally and distally with 4+ dorsiflexion, 5- plantar flexion. He notes particular pain with hamstring activation, and giveway due to that on the left (but did correct to 5/5). His sensation is diminished on the left. His reflexes were symmetrically absent both proximally and distally. He has a flexor response to plantar stimulation. He has no clonus and his tone is normal. Straight leg raise on the right is negative; on the left is positive into the leg at approximately 40 degrees.

Films: An MRI of the lumbar spine from the FACILITY & DATE was reviewed with the patient - this reveals multilevel degenerative disc disease, with no listhesis, no tumor, no other spinal abnormality of concern except for a left L4-5 disc herniation which creates lateral recess and foraminal stenosis, concordant with the patient's symptoms.

Assessment and Plan: Extremely pleasant AGE /PATIENT in good shape with left L5 radiculopathy referable to the disc herniation at L4-5 seen on imaging (pain, tingling, and weakness). We discussed the pathology of the disc herniation and the potential options, both nonsurgical and surgical. I do think he will benefit from L4-5 left lumbar microdiscectomy, especially as he has some weakness referable to this. Decompressing that nerve root will give it the best opportunity to repair, and therefore give him the best opportunity for symptomatic improvement. I encouraged him to think about it, discuss this with his wife, and then get back to me. He potentially is interested in surgery this month, and we discussed DATE 1 vs. DATE 2- he will call my office if/when he wishes to proceed. Should he decide not to have surgery, I would still take care of him if he has any further issues or concerns. I also provided him with a booklet, Care of the Back, for recommendations on exercises and ergonomics.

At 10:45 a.m. we discussed the issue of his cigarette smoking and I counseled him to consider cessation. I explained how tobacco continues to be the leading cause of preventable disease and death in our country, and how smoking can harm nearly every organ of the body. Smoking can be attributed to heart disease, stroke, lung disease, cancer and numerous other conditions. I provided him with a pamphlet. Preventative Services and Tobacco-use Cessation, and concluded my counseling session at 10:52am.

If there are any questions or concerns that you have regarding this clinic visit or any future planning please do not hesitate to contact me. Should he proceed to surgery, I will keep you updated as to his progress."
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
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What about a code for the tobacco habit(305.x) and the counseling for high risk(V69.x). You cannot use the 338.xx code as he never specified acute or chronic. Are you allowed to code the toabacco counseling with the E&M? and do you need a 25 modifier on the E&M?
 

PERRAULT

New
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Location
Spring Hill , FL
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Code A Round E&M

Thank you Debra, The 305.1 was accepted and the note is now complete. :) And to answer your question, yes I was able to code 99203 with 99406 with the modifier -25 on the E&M. Thank you again
 
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