E/M Level 3 or 4 (Hernia)

michelle24

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I'm having trouble determining the level for this New Patient. The HX & PE are Comprehensive, but I'm stuck on the MDM.

This is the A&P:

"I discussed that though he has point tenderness to the area, no obvious fascial defect is palpated in the area. I recommend a CT abd/pelvis to better evaluate the abdominal wall. He will return to the office after the scan to discuss the results & if a hernia is present, will discuss surgical evaluation. All questions were answered. He was encouraged to contact the office with any concern".

This is the HPI:

"He states that on Christmas day, he was lifting his daughter when he felt a sudden onset sharp pain, LUQ just adjacent to his umbilicus. He denies any nausea or vomiting at the time, no palpable masses. The pain continued for 3 days and slowly improved on its own. Since than has felt it on/off with certain movements. He denies any radiation of pain. He denies any dysfunction of bladder or bowel. He worked out recently and did not feel any increase of pain. He denies any obstructive symptoms. He states that the pain is minimal, only on palpation, and does not interfere with his daily activities."

I'm leaning towards 99203 but the MD coded as 99204.

Presenting Problem: New w/ add'l w/u = 4pts
Data Ordered/Reviewed: Ordered CT = 1 pt
Risk: Acute Uncomplicated Illness/Injury is what I feel most comfortable with.

Am I missing something?

Thanks in advance.
 

thomas7331

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I'd agree with 99203 based on how this is worded, but I think this note would be a great discussion tool for education with the provider. With a little more documentation of what they are thinking, this could in fact be a moderate level of MDM. For example, does the provider think the likelihood of the need for surgery is high or low? Is there a possibility that this is something more serious? If so, what? Or is the CT ordered just as a precaution? A few extra words would really clarify this as a 99203 or 99204.
 

michelle24

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Thank you Thomas. I agree & have spoken to her. She actually does state in the A&P, the reason for the CT. It's to evaluate the abdominal wall to see if a hernia is present. I appreciate your input.
 
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