So my Acupuncturist and I have been going back and forth on billing E/M codes for a year now. She recently "beefed" up her documentation and now I really feel stuck. As far as I am concerned the example below meets the requirements of a 99212:
Acute bilateral low back pain without sciatica *- Primary ICD-9-CM: 724.2, 338.19 ICD-10-CM: M54.5
*Neck pain on right side ICD-9-CM: 723.1 ICD-10-CM: M54.2
*
SUBJECTIVE: SUBJECTIVE: Patient is a 37 year old male is here for treatment of back pain and right-sided neck pain. Back pain started last week after lifting something too heavy. Pain is bilateral and across the whole lumbar area. Pain is mild now, but more severe and accompanied by stiffness in the mornings and after sitting for 30 minutes or longer. Negative for radiating pain to hips or legs.
Neck pain is on right side and started this weekend after driving for 8 hours in the rain and then sleeping on it wrong. Pain is isolated to neck and restricts cervical rotation (to left) and extension.
REVIEW OF SYSTEMS:
ROS: General: negative *
Eye: negative
Ear/Nose/Throat: allergies
Respiratory: negative and cough
Musculoskeletal: back pain-acute, morning joint stiffness and muscle pain
Neuro: negative
OBJECTIVE:
Pain is worse with spinal flexion.
Cervical rotation to right ROM decreased by 30%
TREATMENT:
Right - 7 tigers, Ling gu, da bais, LI 4, 22.08, 22.09, SJ 3
Left -* 3 weights, Sp 5.5, Sp 5.75, Sp 6, Ht 5, Ht 6, Ht 7, Gu Cis
ASSESSMENT/PLAN:
DX: acute bilateral low back pain without sciatica - M54.5
Right sided neck pain - M54.2
There are no Patient Instructions on file for this visit.
Return if symptoms worsen or fail to improve.
Then there is this patient which looks like a 99213:
Hot flashes *- Primary ICD-9-CM: 782.62
ICD-10-CM: R23.2
SUBJECTIVE: Patient is a 64 year old female is here for initial treatment of hot flashes, bone loss and general wellness. We are doing acupuncture and an herbal consult today.
Patient went through menopause at age 50. Took black cohosh formula for two years to make the transition. Is now having hot flashes at night. Also gets up 2-3 times per night to pee. Has had declining bone density since age 50. Dx with osteopenia at age 60. Taking supplements. Has a very healthy diet - no processed food, no cheese, low carb, no sugars - and is physically active - running and walking and some weights.
Currently - Hot flashes nearly every night. No excess sweating. Wakes feeling hot - has tried removing blankets, but that didn't help. Is generally cold, with cold hands and feet. Cheeks are slightly pink close to her nose.
Digestion is pretty good - some bloating and gas. Regular bowels. No food cravings.
Sleep - falls asleep quickly. A few times a week will wake at 3-4 and be awake for a couple of hours. Very good at napping. Naps easily and can sleep between 10 minutes and 2 hours.
Thirsty a lot and prone to dry mouth. When she is up to pee at night, always has a sip of water. Has water with her all the time. Very dry lips.
Chronic nasal drip and drainage. Also has occasional sneezing fits. Allergies? But happens year round and no change between Tucson and here.
Easily fatigued in over-stimulating situations (introvert). Doing a lot of internal work on her self - meditation, reading, self-awareness practices.
She has a slight rash from poison ivy on her right hand. It's covered with a bandage.
Pulses: overall strong, leisurely. Sp is full and soft, left Ki is thready and a little tight. Ht thready at deep level.
Tongue: red, wet, raised center. Small horizontal cracks in center. No coat.
Hx: 6th of 7 kids, mother had HTN and stress during pregnancy. Also working on keeping her own blood pressure under control.
REVIEW OF SYSTEMS:
Review of Systems
Constitutional: Negative for fever and chills.
HENT: Positive for congestion.*
Eyes: Negative for discharge and redness.
Respiratory: Positive for sputum production. Negative for cough and shortness of breath.*
Gastrointestinal: Negative for constipation.
Genitourinary: Positive for frequency.
Musculoskeletal: Negative for myalgias and back pain.
Skin: Positive for rash.
Neurological: Negative for weakness.
OBJECTIVE:
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No distress.
HENT: *
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Pulmonary/Chest: Effort normal.
Neurological: She is alert and oriented to person, place, and time. Coordination normal.
Skin: Skin is warm and dry. Rash noted.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment normal.
Vitals reviewed.
TREATMENT:
First 15 minutes: *
Bilaterally - Lu 7, Ki 6, Sp 6
Second 15 minutes: *
Bilaterally - Ki 3
GV 20
HX: Prescribed Restorative Tablets, 3 tabs BID. She is taking supplements that include calcium and magnesium, but also showed her Calmagnium as an option. Will copy information so she can compare.
ASSESSMENT/PLAN:
OM Dx: Kidney and Lv Yin deficiency with Ki essence deficiency.
R23.2 Hot flashes* (primary encounter diagnosis)
Plan : ACUPUNCTURE, 1+ NEEDLES, W/O ELECTRICAL STIM; *
********** EA ADDL 15 MIN PERS CONTACT W/NEEDLE RE-INSERT
********** ACUPUNCTURE, 1+ NEEDLES, W/O ELECTRICAL STIM; *
********** INIT 15 MIN PERSONAL CONTACT
There are no Patient Instructions on file for this visit.
Return if symptoms worsen or fail to improve, for Follow up treatment.
Thoughts?