Wiki Documentation - Level of service

[KoBee]

We have a specialist who seems to always want to enter a level 4 for all their follow up visits. There is a lot of copy and paste from previous visit and HPI updated information shows the patient is doing well, no complaints. But when you get to the MDM, i see the provider enter all chronic conditions with a treatment plan, majority again are copy and paste. I am little confused on making sure visit meets a level 4.

I always thought if HPI nor exam mentioned anything about those chronic conditions, especially if the patient is stating they are feeling well, you can't count all conditions under assessment/plan to support a level 4, or can we?

everything in BOLD is what was updated, everything else is copy and paste from previous visit.


CARDIOLOGY PROGRESS NOTE:

xxxxxx is a very pleasant 75 y.o. male with PMHx of mvCAD with mvPCI with RCA STEMI in 2020, HTN, HLD DM2, Persistent atrial fibrillation Sp ablation of atrial fibrillation 6/22/21 (PVI, Roof, LAA, Box, CTI), Atrial flutter, Chronic anticoagulation who was previously followed by Dr. xxxx.

He had been also followed with Dr. xxx, but he was referred to me given persistent chest pain

He is a gas station owner - had 2 prior (xxxxx and xxxx) but sold the xxxx location

He is still having regular chest pressure - light in nature that is aw exertion. Mild SOB as well. No palptiations
Tolerating medication ok

BP good every day, but today
Did not sleep well
Usually 125/75 at home

Re: Chest Pain
- for the last 2 months
- occurs more at night most of the time

Interval Updates
Doing well since last visit
Sold his station in Colton 3 weeks ago
Now enjoying retirement
Catching up on sleep!

Notes from Dr. xxxxx:

He had developed chest pain and occlusion of the right coronary artery and underwent stenting of the artery by Dr. xxxxx on 8/10/2020.

1. S/P stenting circumflex 7/29/09.
S/P STEMI (inferior) and stenting PL branch 4/19/06.
Vessels patent 10/27/10 and again 7-27-18 Myocardial bridging of LAD and most distal LAD has 75% lesion. Too small to stent.
STEMI and stenting of RCA 8/10/20 with 2 Xience stents by Dr. xxxxx.

Notes from Dr. xxxx:

Hx AF/futter
AF diagnosed on EKG here 3/2021.
Underwent DCCV 4/21/21 at 360 J w/ Dr. xxxx but reverted back to AF

Underwent complex AF ablation 6/2021
No longer on amiodarone therapy

No recurrent afib.
Still on eliquis

CAD
FIrst had stenting in 2006 after myocardial infarction.
PCI to RCA 8/2020


NO longer on plavix or ASA
Claims he intermittently get chest pain and feels a rock on his chest.
Had nuclear in 2022 which was negative.


Hypertensive heart disease
Atenolol, chlorthalidone, ramipril, clonidine
BP controlled

HLD
Intolerant to statin and vytorin
Stopped vytorin due to myalgias

On Repatha

Examination
BP 126/74 | Pulse 81 | Ht 5' 9" (1.753 m) | Wt 206 lb (93.4 kg) | BMI 30.42 kg/m²
General Appearance: Alert, cooperative, no distress, appears stated age
Head: Normocephalic, without obvious abnormality, atraumatic
Eyes: PER, conjunctiva clear, fundi benign, both eyes
Ears: Normal external ear canals, both ears
Nose: Nares normal, septum midline, mucosa normal, no drainage
Throat: Lips, mucosa, and tongue normal; teeth and gums normal
Neck: Supple, symmetrical, trachea midline, no JVD
Heart: Regular rate and rhythm, S1, S2 normal, no murmur, rub or gallop
Lungs: Clear to auscultation bilaterally, respirations unlabored
Chest Wall: No tenderness or deformity
Abdomen: Soft, non-tender, bowel sounds active all four quadrants, no masses, no organomegaly
Extremities: Extremities normal, atraumatic, no cyanosis or edema
Pulses: 2+ and symmetric
Back: Symmetric, no curvature, ROM normal
Skin: Skin color, texture, turgor normal, no rashes or lesions
Neurologic: Non focal



Cardiac Studies
- EKG
Tracings personally reviewed in clinic

01/12/2024
Rate 69. Sinus. Inferior infarct

05/02/2024
Rate 62. Sinus with borderline prolonged AV conduction. CRO inferior infarct

10/11/2024
Rate 64. Sinus rhythm with prolonged AV conduction. Inferior infarct

11/22/2024
Rate 61. Sinus with prolonged AV conduction. Inferior infarct.

03/28/2025
Rate 73. Sinus with prolonged AV conduction with blocked PAD. Inferior infarct


Plan

1. CAD in native artery (Primary)
2. Old MI (myocardial infarction)
3. CAD, multiple vessel
- ASA
- repatha
- atenolol-chlorthalidone

4. Myopathy due to HMG-CoA reductase inhibitor
5. Statin intolerance
Repatha

6. Persistent atrial fibrillation (HCC)
7. S/P ablation of atrial fibrillation
8. Chronic anticoagulation
Atenolol
Eliquis

9. Hypertensive heart disease without heart failure
Ramipril
Atenolol-chlorthalidone

10. Hyperlipidemia, unspecified hyperlipidemia type

- Continue Eliquis
- Plavix every other day helping - will continue
- continue repatha
- continue HTN regimen (tenoretic, clonidine)
- continue farxiga
-sx now improved with retirement and stress reduction
-will plan clinical surveillance



Help!

 

[sdeconda1972]

I took time below to really break this down to help explain the answer.



**Review my comments below**
CARDIOLOGY PROGRESS NOTE:
** All of the subjective info that I formatted in italics is information entered by another physician, who is cited in the blue font below. That is APPROPRIATE use of copy and paste. **
xxxxxx is a very pleasant 75 y.o. male with PMHx of mvCAD with mvPCI with RCA STEMI in 2020, HTN, HLD DM2, Persistent atrial fibrillation Sp ablation of atrial fibrillation 6/22/21 (PVI, Roof, LAA, Box, CTI), Atrial flutter, Chronic anticoagulation who was previously followed by Dr. xxxx.

He had been also followed with Dr. xxx, but he was referred to me given persistent chest pain

He is a gas station owner - had 2 prior (xxxxx and xxxx) but sold the xxxx location

He is still having regular chest pressure - light in nature that is aw exertion. Mild SOB as well. No palptiations
Tolerating medication ok

BP good every day, but today
Did not sleep well
Usually 125/75 at home

Re: Chest Pain
- for the last 2 months
- occurs more at night most of the time

Notes from Dr. xxxxx:



** As you note- this is the "update" to that subjective information from this encounter**
Interval Updates
Doing well since last visit This is considered an interval update- how is the patient improved/worsened since last visit.
Sold his station in Colton 3 weeks ago This is a "history" update to the patient that directly impacts these problems.
Now enjoying retirement This is a "history" update to the patient that directly impacts these problems.
Catching up on sleep! This is an update to a systemic symptom that would have impact to the patients presenting problems.

**This patient historical information was site/sourced for the copy and paste. Best practices- educate the physician in the future to add a comment, no new updates. This verifies that this was reviewed as part of the encounter- although NOT required by 2021 E/M Guidelines.**

**The exam- AMA states when performed it should be documented. therefore, it's not a requirement- but recommend redminding this physician that when carrying forward an exam- it is the same as saying, they performed each element of this exam and those are the same exact findings. Educate that the provider could have noted the site source of this copy paste also and then noted variances or exam repeated and findings remain unchanged.**

**Regarding the treatment plan- pasting with appropriate updates is not inappropriate, but we need to know changes. In this instances, the physician noted the patient is improving and able to move to "survelliance" which implies they are improving, but that is not clearly stated. However, this would typically mostly imply, longer gaps between visits. All of the medications are noted as continue each.


**OVERALL- I can see a physician selecting a 99214 for this patient. there are multiple cardiac conditions that are being monitored. However, AMA Guidelines state that for a problem to be addressed- A problem is addressed or managed when it is evaluated OR treated at the encounter by the physician or other qualified health care professional reporting the service. There is no other requirement- like it must be addressed in the exam, or anything else.

The question to ask is what problems were evaluated or treated in the encounter. As documented, it appears like all cardiology issues were considered more as a group than individual problems being addressed.

For this reason, I would select a level 3, but this provider MUST be educated on why for future improvement.