Wiki Is this consider level 5 MDM without time statement?

[mskitaly09]

I advised provider to include time statement to support level 5. She states pt is qualified for the level 5 visit based on the acuity, not the time. Based on the MDM chart pt was in the high category due to 1 acute illness that poses a threat life and decision to hospital of care.

I still disagree with the provider just based on MDM. To ne this would be consider a level 4 without the time statement. Please advise and see the progress notes below. Thanks in advance for any feedback!

Reason for visit: new pt, physical

HPI: This 57 y/o caucasian female with a PMH of bipolar disorder, HTN, HLD, DM, vitamin d deficiency, insomnia, CVA and COPD is here today to establish. Patient reports dizziness, right arm abnormal sensation, shortness of breath and overall she doesn't feel good. She denies any chest pain.

Assessments:

1.	Dizziness - R42

2. Essential hypertension - I10 (Primary) 3. Fatigue - R53.83 Patient has elevated blood pressure and is symptomatic. EMS was called for patient to report to the local ER.

 

[Cynthia Hughes]

It seems to me that both the diagnostic statement and the ICD-10-CM codes are lacking to support the level 5 visit based on MDM or time. If the patient's blood pressure is high enough to require EMS transport and hospitalization, then I would question whether the diagnosis might be more accurately described as hypertensive urgency (I16.0, I10) with history of CVA and shortness of breath. Differential diagnoses that were considered would, though not reported when not confirmed, would add to the support for the level 5 visit. This may be an opportunity to talk about how the diagnoses should reflect the nature/complexity of the problem addressed and of the medical decision making. Cindy

 

[csperoni]

I agree. The clinician may have provided a level 5 visit, but documented a level 4. "Elevated" blood pressure and "symptomatic" does not clearly demonstrate a problem that poses a threat to life.
I would code this as level 4 and use as an educational example for moving forward.