Wiki Does this note meet 99213 guidelines?

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mshelly87

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We are having our first audit and I would like some input. The Dr. coded this visit a level 3 established pt 99213. Do you think this note qualifies?
Cardiac Problems:

PAF
Symptoms:
He continues to do well and is not limited in his activities. He has been getting regular exercise with a stationary bike or treadmill. He had a normal stress echo (4/07) and a cath that showed only minimal non obstructive CAD(6/07)

Meds:
His meds are listed here but for my question i am not going to list them all

Physical Exam:
Vitals=wt 176, bp: 110/70;pulse 72 resp 18
Appearance: well developed, no distress
HEENT: normocephalic, atraumatic
Chest: clear to percussion, auscultation, no rales, no wheezes
Cardiovascular: Jugular Venous pressure, normal, Heart rhythm reugular, no mumur, rub or gallop notes. Vascular exam, lower extremity pulses are 2+ out of 4 in both legs
Abdomen: soft, non tender. Bowel sounds present.
Extremity: No cyanosis, clubbing or edema
Neuro: Nonfocal exam, normal strenght, movement/balance

Labs/Dats: ECG from today NSR, no acute ischemic changes
Assessment and Plan:
He is doing well on his current meds and is currently in sinus rhythm. I would not make any changes in his cardiac meds at this time. i will schedule him for a f.u in about 1 year.
What do you all think. The dx codes used were 427.31 and 414.01. THanks in advance
 
Hello,

I would allow this to go as a 99213 based on low MDM (2 stable problems) and EPF exam. As an auditor I would comment on the documentation of assessment/plan - Recommend clearly stating the conditions that are being addressed during the visit - i.e. "A-fib - stable, CAD - stable".
:)

Christie Musser, CPC
 
Thanks for your response. I have a question for you. I am having a real problem picking out the elements when they are not clearly labeled. Like our dr used the problem PAF and didn't clearly specify ROS in his report. How do I pick the elements out? LIke he said pt continues to do well and his activity is not limited. What does that count as? We have just starting having the providers use the cc and ros in every note but these notes before that i find very confusing. thanks
 
The "patient is doing well and not limited in activities" is vague but could be counted towards HPI (quality or modifying factors)....a little bit of a stretch. As far as ROS - look for answers to qustions for example: No shortness of breath, no chest pain, no joint pain, headaches occasional, - these would all be examples of statements that could be counted towards ROS even if not labled as "ROS". Sometimes providers will lump all of the history in one paragraph or section and it is up to the auditor to determine the category that the statements falls under. The more you look at notes the better you will become at picking out the elements for HPI, ROS, ect.

Does that help?

Christie
 
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