Wiki New Patient Office Review

[jlb102780]

New Patient Office Review - Please Help

Good Afternoon Coders!

I'm needing some guidance on this E&M office visit. This is a new patient to our practice. The physician submitted a 99205. Based off this report, I am only coming up with a 99202.
History - 2
Exam - 5
MD - 4

History of present illness:
Mr. xxxxx is a 48 year old year old Male.
Patient is self referred to us for management of hypertension and hyperlipidemia. He recently moved to Jacksonville area from Atlanta. Patient is a federal agent for the EPA. States that heated for the above disorders for many years by her cardiologist in Atlanta. Has never had any cardiac issues but does not see a primary care physician. His other medical issues include recurring kidney stones and gout. He is very physically active exercising regularly and has no exertional related symptoms. His only complaint is that of nocturnal leg cramps.

He has had no chest discomfort suggestive of ischemia. The patient denies orthopnea, PND, DOE, or edema. Mr. xxxxx has not had palpitations, syncope or near syncope. He denies claudication. There is no discoloration or ulceration of the lower extremities. He has had no TIA or stroke-like symptoms. The patient has no symptoms attributable to valvular heart disease.

CARDIAC HISTORY
Risk Factors:
1 Hypertension
2 Dyslipidemia

CARDIOVASCULAR PROCEDURES
Electrophysiology:
EKG (Sinus Rhythm, LAD) - 3/5/2013

Interim history: None

Past medical history: Gout, Kidney Stones, Appendectomy, Kidney Stone Treatment, Lithotripsy, Vasectomy

PRE-VISIT MEDICATIONS
Joint Support 375 mg-300 mg-50 mg-2 mg capsule
Take as directed
Lipofen 150 mg capsule
take 1 capsule (150MG) by oral route every day with food
multivitamin with minerals tablet
take 1 tablet by oral route every day with food

Allergies / Intolerances: None

SOCIAL HISTORY
Family: Married, 1 Children
Caffeine: Coffee

Family history: There is no family history of premature coronary artery disease. Family Hx of Hypertension

Review of symptoms:
RESP - Negative for hemoptysis, dyspnea. Positive for snoring. CONST - Negative for weight gain, weight loss, fever. EYES - Negative for visual changes. ENT - Negative for hearing loss. CARD - Negative for chest pain, diaphoresis, orthopnea, palpitation, syncope. Positive for pnd. VASC - Negative for claudication, edema. GI - Negative for nausea, reflux, bleeding. GU - Negative for hematuria, nocturia. REPROD - Negative for erectile dysfunction. ENDO - Negative for goiter, tremors. NEURO - Negative for dizziness, memory loss, seizures. PSYCH - Negative for depression, hallucinations. DERM - Negative for rash, skin sores. M/S - Negative for joint pain. Positive for myalgia. HEMAT - Negative for acute anemia, thrombocytopenia.

Physical exam: CONST - The patient is 5ft 9in tall, and weighs 206lbs. The BMI is 30.5 kg/m2. Blood pressure in the left arm is 123/74 mmHg in the sitting position. The pulse is 65/min. Nourishment - Obese. Appearance - Well Developed. EYES - Lids/External - Bilateral Normal. Conjunctiva - Bilateral Normal. NMT - Oral Mucosa - Moist, No Cyanosis, No Pallor. NECK - JVP - Less Than 8. RESP - Respirations - Nonlabored. Breath Sounds - Clear Throughout. Rales - Absent. Rhonchi - Absent. Wheezes - Absent. CARDIAC - Rhythm - Regular. Palpation - PMI Normal. Heart Sounds - S1 Normal, S2 Normal, No S3, No S4. Extra Sounds - None. Murmurs - None. VASC - Carotid - Bilateral Normal. Aorta - Normal Size. Femoral - Bilateral Normal Pulse. Post Tibial - Bilateral Normal. ABD - Tenderness - None. Hepatomegaly - Absent. Splenomegaly - Absent. M/S - Gait - Normal. Able to Exercise - Yes. EXT - Clubbing - Absent. Lower Extremity Edema - Absent. SKIN - Venous Stasis Ulcers - Absent. PSYC, H - Orientation - Oriented to Time, Person and Place. Mood - Appropriate.

IMPRESSION AND PLAN
01. Hypertension, Unspecified: well-controlled on current therapy. We'll do some routine fasting blood work and continue current therapy.
02. Hypercholesterolemia: last fasting liver profile was proximally 7 months ago and levels were well-controlled. We'll recheck and continue therapy.


Orders:
1 Have a CMP (Comprehensive Metabolic Panel) drawn at the first available time.
2 Have a Lipid Profile drawn at the first available time.
3 Have a TSH drawn at the first available time.
4 Lab ordered: Uric Acid at the first available time.
5 Lab ordered: PSA at the first available time.
6 Lab ordered: Vitamin D, 25-Hydroxy at the first available time.
7 Return office visit with MD in 1 Year.


FINAL MEDICATION LIST
atorvastatin 20 mg tablet
take 1 tablet (20MG) by oral route every day
Joint Support 375 mg-300 mg-50 mg-2 mg capsule
Take as directed
Lipofen 150 mg capsule
take 1 capsule (150MG) by oral route every day with food
losartan 100 mg-hydrochlorothiazide 12.5 mg tablet
take 1 tablet by oral route every day
multivitamin with minerals tablet
take 1 tablet by oral route every day with food

 

[nelstx2]

My FYI, I would have sent it in as a 99203, 2 specific presenting problems, detailed exam, medical decision of low complexity...

 

[jlb102780]

Here's how I came up with the 99202:

History - 2 (Status of 2 Conditions making this Brief)
HPI=2, ROS=5, PFSH=5
Exam - 5 (Comprehensive Single System Exam, Cardiovascular)
MD - 4 (Moderate Completxity)
Mgmt=5, Data=1, Risk= 4 Two or more Chronic illnesses (HTN and Hypercholesterolemia)

I am fairly new to performing these audits, but been coding for 8 years, so any insite and guidance is most welcome

 

[MikeEnos]

I honestly can't figure out what your scoring methodology means. When you say ROS = 5, does that mean 5 systems?? I'm getting different figures.
______________________________________
Level of History:
HPI - This is borderline, I see enough to call it extended but others may call it brief.
ROS - Complete, I saw 12
PFSH - Complete all 3 elements are documented

History: Comprehensive
______________________________________
Level of Exam:
Using 1995 Guidelines
Organ Systems Reviewed:
-Constitutional
-Eyes
-ENMT
-Respiratory
-Cardiovascular
-GI
-Musculoskeletal
-Skin
-Psychiatric
-Heme/lymph

Exam: Comprehensive (8+ organ systems)
____________________________________________
Medical Decision Making Complexity:
Diagnoses - Multiple - 3 (2 new problems to the examiner with no additional workup, 3 points each, maximum of 1)
Data - Minimal - 1 (Labs Ordered)
Risk - Moderate (2 or more stable chronic illnesses, prescription drug management)

Overall Complexity: Moderate
_________________________________________

So Putting those key components together we have a new office patient with:
- Comprehensive History
- Comprehensive Exam
- Moderate Complexity Medical Decision Making
This satisfies 3/3 components for a 99204

If you felt the HPI was brief that would hold it back to a 99202, but I would say it is borderline at best.

 

[LLovett]

I agree with Mike except for the Dx points but ultimately it doesn't matter.

HPI is kinda ugly but it is there. The last sentence in the first paragraph gives you 3 elements by itself, timing, location, and quality. You can either pull modifying factors or associated signs and symptoms to get your 4th element.

In Dx he is ordering labs for both issues so I would call them new with work-up.

Just my take on it,

Laura, CPC, CPMA, CEMC

 

[jlb102780]

Thank you so much for the help everyone! This E&M auditing is very new to me.

Mike, the ROS=5 just meant what level I came up with based on the documentation, so I was saying it was meeting a Complete review. I do like how you broke this report down in detail, it was much easier for me to understand.

Thanks again