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I need to some insight on this encounter note. Provider feels that it is a high level encounter while I feel it should be down coded. I would like to get others views on it for education for him and myself.

Thank you.
 

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You may use July 2024, AAPC magazine page 27-29 as a reference for the PCP. In addition, according to the MR, the Pt is not in acute distress and A&P is only for medication management and referral; maximum LOS would be 99213 (99203) EM. Also, the provider recorded "onset of skin carcinoma" but does not assess it.
 
Do you have another provider in your group that "gets it"? Is there a coding advocate or peer provider that you can enlist help from? I have found that sometimes when working with difficult physicians, it can help to involve one of their peers. I could say the same thing the other provider is and while the provider being educated will not listen to me, they listen to their peer.

This note is all over the place, it's not really code-able in my opinion. If it were cleaned up and everything aligned, you could probably see a level 4 here. This patient does appear fairly complicated and there are multiple chronic issues in the moderate column along with prescription drug management. It is not a level 5, if that's what you mean by "feels everything he does is a high level E&M". There could be a case for coding by time possibly. It depends on the documentation and how long it took and it would have to be correctly noted.

The chief complaint in that note is not great. Why are they there for f/u? it would be better to take the 1st sentence of the HPI and use it in the cc section. The problem list does not align with the note and the A/P. For example, one spot states Fracture of humerus - Onset: 10/22/2024. The another it shows, Left Closed fracture of proximal left humerus - Onset: 12/18/2024. Makes no sense.

The MSK exam conflicts with the HPI and the neuro exam section. For example, MSK states: "Musculoskeletal: Normal range of motion and strength, No tenderness, No swelling" but then the HPI states "presents status post total replacement of her left hip. She is in a WC", "She still can't walk and she is WC bound.", "Her left upper extremity she has little use and she has 1+ edema", and goes on in more detail about MSK issues. How is that normal ROM & strength and no swelling?

The A/P does not fully go along with the rest of the note. #1 just says history of total joint LT hip and presence of THA. Seems there is more wrong and more going on there than that. #2 is stated but in the psych exam there is nothing about it and does not appear that it was addressed at all except some meds in the med list but they do not show as refilled or filled on the DOS. #3 was in the HPI and Cipro noted, and what looks like an outside lab? Or, was the lab done in office? If so, where is the result?
#4 states to continue the med. #5 was discussed. #6 the med was cont. and talked about in the HPI. #7 states "S42.202A: Unspecified fracture of upper end of left humerus, initial encounter for closed fracture" when was the fracture? You have an active, initial diagnosis for something which appears to be old. Note state loss of function. HPI states, "Her left upper extremity she has little use and she has 1+ edema." This does not appear to be a new fracture. Is it a late effect? Is it healed with complications? Is there a non or malunion? And again, here, the MSK exam conflicts with the neuro exam of the LUE.

This is stated in the HPI, but not addressed anywhere else, appears to be managed by another provider. "She has a cancer on her ant chest wall the size of a large marble. Apparently some kind of SCCA that is to be removed in 2 days."
 
I agree it's not the best note, but I have seen worse. I would code this as a 99214. He's got a history and exam. For MDM - you easily have Moderate in the Number and Complexity of Problems without even considering the fractures (2 or more chronic stable with the anxiety - stable and OAB - continue med, check UA) and you have Moderate for Risk of Complications and/or Morbidity with the prescription drug management. Two/three Moderate = Moderate for MDM.
 
I need to settle an issue I am having with one of my family practice providers. He is older and feels everything he does is a high level E&M. I am trying to explain to him that he is not hitting the criteria.
I would be interested in what other coders would code this encounter? Please look at it and let me know. I am using this as an education for him and myself.

Thank you.
TLS,
Id let him read the CPT manual for CPT 99215 or 99205 that is high level MDM making. I ve been told true emergency transfer to hospital or ongoing Cancer dx with suffering symptoms or life or death soon. This pt would get 99214 cpt for visit. You might tell provider if he give CPT 99215 for all pts...red flag to payers who will or might pull funds back.
I hope this helps
Lady T
 
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