Wiki Need help most appropriate E/M level for OV

[cwestman]

Reviewing encounter for recent TOC(established patient) visit with what could have been a moderate to high level MDM. However patient has Medicaid coverage so 99495 and 99496 is not usable even if MDM was moderate Diagnosis are of a higher complexity but confused by lack of MDM
I'm wondering if anyone would help advise on most appropriate E/M
Every aspect of HPI and history and Exam is detailed/ to comprehensive, no coordination of care was documented I'm just not certain what is most appropriate given the complexity of dx verses MDM
Assessment:
1. Body mass index (BMI) of 19 or less in adult - Z68.1 (Primary)
2. Acute ischemic right MCA stroke - I63.511, Appreciate recent hospitalization Continue rehabilitation
3. Hemiparesis of left nondominant side due to non-cerebrovascular etiology - G81.94
4. Other symptoms and signs involving cognitive functions and awareness - R41.89
5. Hypertension - I10, Patient is at goad: <140/90 per JNC 8 Guidelines - Blood pressure was in range. Taking medications as prescribed. No medication side effects noted. Continue monitoring blood pressure at home/record flow-sheet, bring for review.
6. Wolff-Parkinson-White syndrome - I45.6
7. History of coronary rotational ablation - Z98.890
8. Status post placement of implantable loop recorder - Z95.818, implanted on 2/23/18
9. Anxiety - F41.9

Plan:

1. Others
Notes: Reviewed and encouraged compliance with current treatment plan
Notify doctor if any changes or concerns
Warrents close follow-up.

Would really appreciate any help or advice
Thank you Cheri

 

[thomas7331]

If your History and Exam qualify as detailed or higher, I would code this as 99214. Some auditors might assess the MDM here as low for only two stable diagnoses actually addressed (stroke and BP), but the medical necessity certainly supports a level 4 due to the recent hospitalization and comorbidities, so there's no reason not to code that level if the first two elements qualify.

 

[cwestman]

Thank you!!!!

 

[mitchellde]

What was the reason for the encounter? I am confused by the diagnosis listing. We know the I63.511 is not correct for this encounter, but it is unclear how recent the stroke was. The provider marked the BMI as primary which we know it cannot be but why did the provider feel that that was the primary. Then there is a non stroke related hemiparesis, and the pre excitation syndrome thrown in for good luck. The HTN is stable and so on. So it looks like maybe it could be a level 4 with all that but really were all those things addressed at this visit? It looks to me like a culmination of diagnosis from several past encounters and thrown together. So what was the reason for the visit, and what did the provider address.