Wiki E/M Coding

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risnerclan

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I want to post this office visit out and would like some input on how you would code this level of E/M.

Thanks!

CHIEF COMPLAINT:
Follow-up, low back pain.

HISTORY OF PRESENT ILLNESS:
His symptoms have improved with rest and physical therapy. He has had his MRI scan. The Aleve is helping. He has not returned to basketball.

SYSTEM REVIEW:
Neuro: Transient tingling in the left lower extremity.
GI/GU: No change in bowel or bladder habits.
Constitutional: No fever, chills, night sweats, or unintended weight loss.

MRI:
The MRI report showed degenerative disk disease at L4-L5, L5-S1 with a mild to moderate broad-based posterior exophyte and left paracentral disk herniation featuring inferior migration along the L4 vertebral body. There was also central canal stenosis, lateral recess stenosis, but no foraminal stenosis at this level. There was also a herniation at L5-S1.

His left hip MRI scan was interpreted as normal without evidence of avascular necrosis or slipped capital femoral epiphysis. No obvious sign of labral tear.

IMPRESSION:
Two-level disk herniations.

PLAN:
1. Continue to withhold from basketball.
2. Sterapred DS, 12-day Dosepak.
3. Physical therapy.
4. Recheck in 2-3 weeks and if not improved then consider lumbar epidural steroid injections.
 
Based on the information provided I would assign 99212 for this established patient ("follow-up").
I see 3 HPI elements: location (back), severity (improved), and modifying factors (rest, PT, Aleve);
there is no exam;
the MDM is straight forward: 1 improving problem, MRI is the only data point, Risk is moderate due to prescription meds.

If your provider actually looked at the MRI imaging and not only the report this could get 2 data points, but your documentation as shown does not indicate such.

Hope this is useful,
Karolina, CPC
 
yes it was thanks...

i normally do surgical coding but was asked to start auditing e/m do you have a cheat sheet of some sort you use when you code e/m?

thanks!
Carol
 
Not Billable

There is no exam documented so in order to code the level of E/M you would need to use the history and medical decision making. One of the components of history is PFSH. I do not see any PFSH. Also, you cannot use your chief complaint twice. (i.e. for CC and for HPI) This note, as written, is not billable.
 
But for the lower levels you do not need to have the PFSH. If your documentation has between 1 and 3 elements of HPI, even if there is no ROS and no PFSH you still have a Problem Focused history. In the scenario there are at least 2 HPI items (though I would consider low back the location, but it is also part of the chief complaint and different carriers may view this differently), there are several ROS items mentioned - so the 1 needed for an Expanded Problem Focused History is definitely there. For this level you do NOT need a PFSH, and therefore an EPF history is documented.
This EPF history together with a Straightforward MDM supports a 99212.

If you go to http://www.medicarenhic.com/providers/articles/E_M_complete.pdf (instead of retyping, just copy and paste) you will find a lot of info regarding E/M and beginning on page 7 a good worksheet
I also would suggest to google "E/M worksheet medicare" (no quotes) or something along that line to see if you find something from your local carrier.
 
99212

I agree with Karolina ... although I would not count the CC as part of HPI.
Still for an EPF history you only need 1 element in HPI and a problem-pertinent ROS. You have that.

I'd code a 99212 established patient visit.

F Tessa Bartels, CPC, CEMC
 
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