Wiki E/M Level - Upon my review of the chart below

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msingh23

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Upon my review of the chart below I have justiy for New Patient Level 4, However Dr. says base on pt Dx this should be New pt L3. Any comment appreciated ..
Note: PFSH all three are valid the per their auditing department None is valid because iss was address.

Initial Orthopaedic Assessment
Ref src: Previous Patient
Employment: Fashion

Vital Signs
Height: 82 inches

History

CC: L-sided lower back pain

HPI: has been having some LBP over the last mos - this weekend was doing an exercise class and got some LBP during the class pain got worse over the next few days. Getting some L buttock pain - achy and stiff in the LB - No LE paresthesias.
Better w salon pas patches, lying flat.
Worse w sitting. No prior PT or imaging done.
PMH: anxiety
PSH: none
FH: none

FLUOXETINE HCL 20 MG TABS (FLUOXETINE HCL)
MOBIC 7.5 MG TABS (MELOXICAM) 1 tab by mouth 2 times daily for 7 days then as needed

Allergies: No Known Allergies
Pregnant? N
Pain site: LB worse
scale: 8
Living environment: apartment

RISK FACTORS
Alcohol use: Y
Average drink(s) per day: <1


Review of Systems
Constitutional: No Complaints
ENT: No Complaints
EYE: No Complaints
Gastrointestinal: No Complaints
Cardiovascular: No Complaints
Genitourinary: No Complaints
Neurological: No Complaints
Psychiatric: No Complaints
Endocrine: No Complaints
Hemato/Lymph: No Complaints


Eyes: NO SCLERAL ICTERIS

Pulses
RLE pulses: present and palpable
LLE pulses: present and palpable

General
Appearance: well developed, well nourished, no acute distress

Lymphatic
Nodes: no LE edema

Gait
Inspection: normal

Skin
Appearance Normal
IR/ER: negative

Lumbar Spine/Pelvis
Range of motion: pain w flex and ext and SB L
Somatic: normal
Palpation: + TTP L SI jt

Special Tests
Slump: negative
IR/ER: negative
SI joint: positive L
SLR: negative

Right Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength

Left Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength, 4/5 hip abd/ext

Neurologic
Coordination: normal coordination
Reflexes: 2+, symmetric, no pathological reflexes
Sensation: intact

Mental Status Exam
Orientation: oriented to time, place, and person
Mood and affect: no alteration in mood or affect

Problems including current update:

BACK PAIN, LUMBAR (ICD-724.2)
ROUTINE GYNECOLOGICAL EXAMINATION (ICD-V72.31)
SCREENING EXAMINATION FOR VENEREAL DISEASE (ICD-V74.5)

Impression BACK PAIN, LUMBAR (ICD-724.2)

Plan
trial of mobic 7.5 mg two times daily,xray LS spine r/o DDD, f/u 4-5 wks if still pain MR

Patient instructed for potential side effects and complications of prescribed/administered medication(s) and agrees to consume and/or receive it/them., Start Physical Therapy, Reviewed HEP, Continue HEP, Ice area 10 min. on 10 min. off for 30 min.

Services & Orders
X-ray exam, lumbar spine AP/lateral/oblique [CPT-72010]

PATIENT EDUCATION
Barriers: None
Teaching method: discussion with patient
Pt significant other(s) can verbalize/return demonstrate instructions.

Thank you.
 
I agree with your provider, based on the presenting problem I get a level 3 as well. He does not document a gyn exam nor a pap screening, why is that in the impression? The MDM is moderate and I get detailed on the exam.
 
I just noticed something above that makes it ESTABLISHED patient rather than new.

Direct Quote from the post:
Initial Orthopaedic Assessment
Ref src: Previous Patient
Employment: Fashion
Click to expand...

Emphasis added.
I could be wrong but I see that and think not New.
 
new pt

The last post is correct...........this looks like it could be an est pt cpt not New. Provided that patient had been seen by this dr in the past 3 years. If that's the case 99214. If the patient hasn't been seen in the past 3 years then 99203
 
Thanks all for your input, however I am still having a challenge understanding why New pt 99203 and not a New pt 99204? Will appreciate some more insight.
This is a new patient never seen before, Ref src is Referral source came from a previous patient (Not the patient was a previous patient). Does presenting problem over ride or a major contributor in the credit given then documentation credits obtain? Patient came in with back pain scale of 8 and was given Prescription drug management with the following:

History
HPI =4> elements
PSFH = 3 areas
ROS= 10 System
Comprehensive

Exam
8 Organ systems
Comprehensive

MDM
New prob w/addition work up - Xray order, Prescription drug management.
Moderate

Impression: is lower back pain

Any input for a better understanding, what or where I am giving incorrect credits.
Thanks
 
Debra Hirshfield, RHIT, CPC

I would not count none in the PMH or PSH. The response of none doesn't indicate that a question was asked or answered. This would count as one in the PFSH which would bring the overall history to a detailed.
 
I also would not count the None for the social and family history. I would give 1 point however for social history as it does mention the patient lives in an apartment - but this would still leave the history at a detailed level.

For the exam, I am only counting 7 organ systems: contitutional, eyes, cardio(pulses and LE edema), skin, muscularskeletal, neuro and psych - so I would say that it is detailed, not comprehensive. I would not give credit to the lymph system as under that heading he mentioned LE edema and nothing about the lymph nodes.

So with a detailed history and exam and moderate MDM this would be a 99203.

Hope that helps.
 
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