HELP! pulmonary audit

michiboo

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I need others opinions and eyes in for a pulmonary provider audit.. This provider is billing 99215, but it looks like most times there is cloning of documentation especially for follow ups, in the follow ups, the provider is just putting the date patient seen with a brief note at the bottom of HPI.. no changes in PFHS so looks like an EPF HPI, exam EPF/Detailed, Assesment/plan a Detailed/Comp, would think a 99214 but not 99215



here is an example:

HPI

81 yo female with history of OSA, CKD, Atrial Fibrillation, HTN/HLD, and ?COPD referred for evaluation.
See PRIOR 2015/16/17 Notes

03/22/2017-She states she feels ok. She still has the chronic cough and congestion but she states she has chronic bronchitis. She states that the she was on Doxycycline and broke out in to a rash on her chest and on her groin. She was seen by her primary and dermatology for the rashes. She is currently taking Gentamycin, but was unable to get her other prescriptions. She is being followed by her other specialists for rash
5/17/17-Coughing less. Feeling pretty good. Using Advair and Spiriva daily. SOB seems stable
8/15/17- She is doing well. she is doing well
10/31/2017- She is about the same. PFT done. She is having knee surgery next month.
1/16/2018- She has been at rehab, She was at Villa Rehab, had the flu, viral infections. When she is walking with the rehab walker and noticed she is much more short of breath. She has not been able to use CPAP at the facility.
4/18/2018- She fell after going home and has struggled since then. She notes that she has had a productive cough since then.  Has a cough that feels deep in her chest. Hoarse. Color is yellow and increased in amount.
5/9/18-Never received augmentin due to allergy with PCN. PMD gave her Bactrim. She is still coughing. Bringing up lots of yellow mucus.  She has a rattle in her chest.
6/27/2018-  She went to Simon Med for her CXR so we will call again for results. Has congestion and coughing. Has atypical stomach and chest discomfort, cleaned cabinets yesterday. States it may be her bladder or GERD, tried Nexium and water. Notes 'milk normally makes it go away." States she can not go to ER she has to go to bank.
10/17/18-Was hospitalized; S/P Chole now. Coughing, SOB, bringing up clear phelgm. CT Chest done at Simon Med
5/29/19 - Was at RCH during many missed appointments per patient. Had PFT 11/2018. She is not using CPAP. At rehab they would
9/4/19-She has been coughing for 4-6 weeks. She wakes up all the time coughing. She has been using nebulizer with minimal improvement.

9/25/19 - Patient is doing well. She finished antibiotics and is doing better, then returned and resumed with no change. ? Related to her CPAP machine.



Review of Systems
Constitutional: Positive for malaise/fatigue.
HENT: Positive for congestion.
Respiratory: Positive for cough, sputum production, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Positive for heartburn (on nexium).
Neurological: Negative for headaches.
Psychiatric/Behavioral: The patient has insomnia.

Objective:
Physical Exam 
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple.
Cadiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Capillary refill takes less than 2 seconds.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.

ECG:
6/2014 Last ECHO EF 72% mild AR/MR, moderate to severe TR
8/23/2016 ECHO EF 73%, PAP 42mmHg

Imaging

7/2015 HBG 12.7, cr 1.0.1
2/4/2016 IGE 55, AST 20 ALT 29
6/24/2016 IGE 40 AST 26 ALT 22
9/2016 IGE 43
11/2016 IGE 64
2/2017 IGE 40
03/16/2017 IGE 36
10/31/2017 IGE 39

Labs:
6MWT/Overnight O2/Sleep:
Pulmonary Function/Spiro:
09/15/2015 Spirometry FVC 1.22L 50% FEV1 1.00L 50% FEV1/FVC 99%
10/13/2015 PFT FVC 2.05L 71% FEV1 1.46L 86% FEV1/FVC 109% TLC 83% RV 102% DLco 62% DLva 82%
4/6/2016 PFT FVC ( 2.20L) 77% FEV1 ( 1.76L) 84% FEV1/FVC 108% TLC 92% RV114% DLco 56% DLco/VA 73%
10/12/2017 PFT  Results: FVC is 2.52L, 90% predicted.  Post-bronchodilator 2.48L, 88% predicted.  FEV1 is 1.94L ,94% predicted.  Post-bronchodilator 1.97L, 96% predicted.  FEV1/FVC is 0.77L, 105% predicted.  Post-bronchodilator 0.79L, 108% predicted.  There is no bronchodilator response.  TLC is 82% predicted.  RV is 76% predicted.  ERV is 50% predicted.  DLCO is 60% predicted corrected for alveolar volume 72% predicted.
11/2018 PFT:   FVC is 2.27L, 81% predicted.  Post-bronchodilator 2.28L, 82% predicted.  FEV1 is 1.79L ,88% predicted.  Post-bronchodilator 1.75L, 86% predicted.  FEV1/FVC is 0.79L, 108% predicted.  Post-bronchodilator 0.77L, 105% predicted.  There is no bronchodilator response.  TLC is 78% predicted.  RV is 76% predicted.  ERV is 54% predicted.  DLCO is 44% predicted corrected for alveolar volume 50% predicted.

9/16/19 PFT Results: FVC is 1.94L, 70% predicted. Post-bronchodilator 2.12L, 77% predicted. FEV1 is 1.64L ,82% predicted. Post-bronchodilator 1.70L, 85% predicted. FEV1/FVC is 0.85L, 117% predicted. Post-bronchodilator 0.80L, 110% predicted. There is notable bronchodilator response. TLC is 78% predicted. RV is 71% predicted. ERV is 86% predicted. DLCO is 60% predicted corrected for alveolar volume 69% predicted.

Assessment:
Hypersensitivity Pneumonitis
-with acute exacerbation; start prednisone taper.
-PFT a year 9/2018
-Self D/c'd Prednisone, has not had flu x 6 months
-Needs PFT annually q6 months, 9/2019 TLC 78%, 2018 78%
-HP panel negative .
-close follow up
-PFT 11/2018 TLC 78%, DLCO 44%
-CXR 9/2019 reviewed, no gross infiltrates noted
Severe OSA
-AHI of 48.6 on sleep study.
-needs CPAP of 9 with face mask, delivered tomorrow
-run SIM card with each visit
-Repeated sleep study: done needs CPAP 16, only tolerates 14; needs to use. Needs new mask.
Aspergillus on bronchoscopy, s/p  treatment.
-IGE normal at 64 but slight increase since 9/2016 to 43. Repeat IGE level now 39.
-Normal IGE levels, AST/ALT on tx of aspergillus
-Holding  Itraconazole and Prednsione, s/p 100mg po daily and prednisone 10 mg po dailyX 3 months. -Not taking ENELBREX
-repeat cultures on bronch negative.
Asthma/Chronic bronchitis- non smoker, significant second hand smoker exposure
-She does not have evidence of obstruction on PFT.
-acute exacerbation start z--pack and prednisone.
-Chronic mucus production, on Mucinex
-Never Smoker
-On Advair/Spiriva/ProAir and Duonebs PRN
-Continue singulair once daily
-Because of sotalol use she can not take daily Azithro
Allergic Rhinitis- on certrizine,continue singulair, Flonase
Reduced diffusion capacity
-DLVA now 68%, was 44%
Mild pulmonary hypertension- likely multifactorial 2/2 lung, heart disease.
-RA and RV normal size.
-Continue optimization of her underlying lung and heart disease.
-Restart CPAP at 14.
-Needs to use consistently
-Used phen phen only for a few weeks.
GERD on PPI (nexium)
Hoarnessss for years, no airway inspection and patients mother had throat cancer, bronchoscopy without lesions.​
Patient Instruction:
Run SIM card next visit
Plan:
Start z-pack and prednisone taper.
Order CPAP 9 per titration with face mask --> new machine to arrive tomorro
Needs PFT NOW 6-12 months
Using Flonase.
Continue nebulizer as needed --> encouraged use
Continue advair and spiriva.Use Singulair once dailyHas generic ZyrtecHas Flonase nasal sprayOptimized for surgery from a pulmonary standpoint​
FAX NOTE:


Follow Up Appointment: Follow up after Surgery, November/December

 

zoinks071

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I can see your dilemma, I also have providers who also seem to just pile on additional notes in a running fashion. It makes it hard to distinguish what is new data from old.
I think I would actually agree with the provider's 99215 and here is my logic on this...

I would agree that the History is EPF. 3 HPI, 7 ROS, 1 PFSH
The Exam is Comprehensive, Constitutional, Eyes, Cardiac, Pulmonary, GI, Neuro, Skin Psych. 8 organ systems = Comprehensive Exam
The Medical Decision Making is tricky because there is so much information all lumped together but I would consider it High MDM overall. Here's how I audit it...
Patient has Hypersensitivity Pneumonitis with acute exacerbation requiring prednisone taper. So you have an established problem worsening - 2 points under number of diagnoses/management options.
Patient has at least 2 other stable established problems, say the Obstructive Sleep Apnea and Pulmonary Hypertension. So adding 2 points more maxes out the number of DX at 4 points.
On top of that the patient has severe obstructive sleep apnea, so their level of risk is high with one or more chronic illness with severe exacerbation, progression, or side effects of treatment.
So overall I would code these elements as EPF History, Comprehensive Exam, High MDM.

I can see why it becomes frustrating when you have providers that build notes with massive amounts of data and think that the oversize quantity entitles them to a level 5, but in this case I think it's actually supported.
Hope this helps. :)
 
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