Wiki E/M on Established patient and surgery


Hamilton, VA
Best answers
Would like to know what level this IH [interval history] on this patient should be coded:

Patient: Name
DOS: 6-14-2012

IH: The patient comes in for follow-up of the bilateral knees. The left knee is doing great, status post scope. The right knee is giving him trouble with mechanical symptoms such as locking, buckling, popping and pain. He says it feels like the left knee did prior to surgery and he would like to have an arthroscopy. I described the procedure, risks, and complications to him; the fact that he might not get better and might be made worse; risk of catastrophic outcome, including loss of limb or life, risk of infections, clots, arthritis, stiffness, nerve damage, RSD, tendon damage, recurrence of the problem, and the need for further surgeries, etc. The patient understands and the surgery will be scheduled at his convenience.

Doctor's name

DX: 717.2, 715.36, 719.46, V67.59 per coder's choice and MRI results.

Am I looking at a 99212 or 99213?

I see only a 99212 (barely) but then I do not see your dx codes. I see the knee pain but no osteoarthritis, no internal derrangement, and the V67.59 is for the other knee which really was not address nor examined. SO the only dx code from this notes is the 719.46
I would also put a 57 modifier on the level.

I would say 99213
The history is expanded problem focused
Exam- I dont see documentation of an exam of the knee
MDM- Low complexity
I hope this helps

Melanie Lewis, CPC, CEMC
Physician Education & Documentation Coordinator
E/M and Surgery

Thanks for the replies.

I coded a 99213.

I pulled the diagnosis' from the MRI report that was in the chart and which the doctor had ordered prior to this visit. We always have an intake sheet on followup appointments also that the nurse records on her interview with the patient, before the doctor comes in.

Any other suggestions the doctor or I should have done will be great.

Thanks again,