Wiki MVA or WC code reduction

[lataashwini23@gmail.com]

Most of our claim price get reduce and the reason is "records do not substantiate this level of service . this code is being reimbursed as 99202 to accurately reflect the service described. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components. A detailed history examination, medical decision making of low complexity. counseling and/ or coordination of care with other qualified health care professionals, or agencies are provided consistent with nature of the problem and the patient's and / or family needs. usually, the presenting problem are of moderate severity. topically, 30 minutes are spent face to face with patient and / or family.

im not sure what we are missing from the chart note. can any one please help.

Chief Complaint: MVA back neck injury 7.21.19 History of Present Illness: He was a restrained driver and collided at 65 MPH with bales of hay which fell out of a truck he was behind he struck the bales as had no other way to escape and this totaled his car. He wasn't seen medically until today he is a package handler and had to miss work due to this injury. Review of Systems: Constitutional: Denies Fatigue , Fever , Chills and Night sweats Eyes: Denies Eye pain Cardiovascular: Denies Chest pain and Irregular heart beats Respiratory: Denies Shortness of breath Gastrointestinal: Denies Nausea and Vomiting Neurologic: Denies Altered mental status Physical Exam: Constitutional Appearance: No distress He has palpable tenderness cspine he can turn rt and left 70 degrees he has palpable tenderness LS he can only flex to 50 degrees no foot drop negative straight leg Head and Face: Normal Eyes Ears Nose Mouth and Throat Ears: External Ears: Symmetric; Hearing: Unremarkable Throat: Normal Neck: Normal Skin and Subcutaneous Tissue: Normal Neurologic Cranial Nerves: Facial Nerve: No asymetry for facial droop Psychiatric: Normal Vital Signs: Temp 97.80 F, Pulse 70 b/m , Respiration 12 b/m, BP 118/76 mm/Hg - Sitting - Left Arm - Standard Cuff Size SAO2 99% , - Manual Recording Taken on Jul 23, 2019 at 5:02 PM by MA Hansen, Feliceti Allergies: NKDA Current Medications: Patient currently takes no medication Assessment And Plan:3 views of cspine reviewed which were negative I suggested Wellness referral (chiro/LMT/Acupuncture) he declines this will recheck in a week he is written off work until then Radiology Order: 07/23/2019 CERVICAL 3V(CPT-72040). 3V C-Spine XR obtained with proper shielding used. Patient tolerated well with no complications. Sent to Tandem for review. Taken by Feliceti H. MA/LXMO Diagnoses: Sprain of ligaments of cervical spine, initial encounter - S13.4XXA Sprain of ligaments of lumbar spine, initial encounter - S33.5XXA Sprain of ligaments of thoracic spine, initial encounter - S23.3XXA Prescription: Zanaflex 4 MG Oral Tablet: 1/2 to 1 po HS to relax muscles, Start 07/23/2019, Qty 15 Tablet(s) For 15 Day(s) traMADol HCl 50 MG Oral Tablet: 1 or 2 po q 6hrs prn pain, Start 07/23/2019, Qty 30 Tablet(s) For 7 Day(s)

 

[mitchellde]

You do not have a PFSH documented which will make the history expanded problem focused so the visit cannot be above a 99202.

 

[thomas7331]

My understanding is that the documentation of allergies 'NKDA' and no current medications could be counted as PFSH. So I would disagree with the payer's reduction of the code level to 99202 based on this documentation. However, there is much that the provider could do to build a better case here, besides adding additional PFSH. In particular, a better history (e.g. more detail about the injury itself, e.g. what parts of the body were involved, what the patient's complaints were following the accident) would give better support for medical necessity of the remainder of the physician's work that is documented here. As the note standing, the history suggests that the patient really had no physical complaints and was simply getting checked because he had been in an accident, and that the provider just happened to discover these sprains during the course of the exam. In other words, the payer may be thinking that if the patient felt fine, then why did the provider need to do all this? Just my thoughts, but you may wish to appeal this, or to speak with your payer directly, which would give you better insight into what they're looking for in their documentation. Hope this helps some.