Wiki Opinions on level of problem

[csperoni]

I am currently in a rather heated debate regarding the level of problem on the below note. I've answered thousands of questions here, and would love for others to weigh in with their opinion. Here are the relevant note portions:
PT is being seen for an initial visit for UTIs.
Primary Chief Complaint: urine frequency.
Secondary Chief Complaint: urinary urgency.
Tertiary Chief Complaint: nocturia.

History of Present Illness
40yo presents for UTIs. Reports feeling of vaginal itching and burning with many neg Ucx at UC. Was at the hospital yesterday for behavioral reasons and was prescribed antibiotics but unsure why. Has occasional urgency and frequency. Denies UTI symptoms today. Presents with aid

PMH: bipolar, depression, schizoaffective disorder, cognitive delay, asthma, GERD, hep B, HLD, HTN, hypothyroid, ulcer
PSH: chole

Day time voids: every 30 mins
Nighttime voids: 3
SUI: no
UUI: no
Urinary urgency: yes
Bladder irritants: coffee, tea, soda, tomatoes, chocolate, citrus
BM: constipation - Miralax/Senna
Fecal Incontinence: no
Vaginal bulge: no
Prior treatment: no
Voiding dysfunction: no incomplete bladder emptying
Lower urinary tract/vaginal symptoms: unsure UTIs in past year, no hematuria
Sexually active: no
LMP: no periods due to meds
Pap smears: 2024, normal
Labs and chart reviewed: yes

Review of Systems
All other reviewed systems are negative.

Physical Exam
Constitutional: in no acute distress and well developed.
Neurologic/Psychiatric: oriented to person, place, and time and memory was unimpaired.
External Genitalia:. normal external genitalia.
The labia majora were normal.
The labia minora were normal.
Urethral Noted: negative CST.
Urethral meatus: was normal.
Urethra: was normal.
Vagina: general appearance was normal . scant discharge, no pain.
Prolapse Assessment:. elongated anterior cervical lip; no visible POP, exam limited.
Cervix: normal.
Uterus: normal.
Bladder: no abnormalities and post void residual was 80 ml.
Rectal exam: was deferred.

Assessment
Urinary urgency (788.63) (R39.15)
Nocturia (788.43) (R35.1)
Frequent urination (788.41) (R35.0)
History of UTI (V13.02) (Z87.440)
Vaginal discharge (623.5) (N89.8)

Discussion/Summary
40yo with UTIs vs OAB. Neg CST and normal PVR.

-Vaginal and urine cultures sent, will treat accordingly
-Advised to test urine when UTI symptoms and f/up with obgyn for vaginal discharge going forward
-Discussed hydration, hygiene habits and supplements for UTI. Discussed abx prophylaxis if needed in the future.

Would you consider this a straightforward, low, moderate, or high problem level?? I appreciate and and all input, whether an experienced or novice coder.

 

[amyjph]

If I was being generous, moderate: chronic exacerbated (many neg Ucx at UC) (Lower urinary tract/vaginal symptoms: unsure UTIs in past year). Also, because of the secondary and tertiary complaints. Would be better if the note gave the timeframe of how long & how many. If this is an OBGYN and an initial visit, that probably means they have been through the ED and the PCP already so to me, it sounds more chronic. How did they get referred here to this provider? Got abx in ED yesterday but doesn't know why? Not BH related, probably due to UTI.
Did the aid give any history? We don't know but with the PMH issues they probably did. If they did with the 2 tests that could push it to a 4 Mod/Mod/Low.
Labs and chart reviewed: yes (would be better if it indicated external labs, external chart or internal info.)
You're probably debating between 3 & 4? Taken at face value without any inference, from an auditor, it's a 3.
Looks like this might be an educational opportunity re: documentation improvement.

 

[natashalage]

Hello Christine! When I saw your post, I was surprised "What??" I told myself, "It's impossible that Christine has a question!" First of all, Thank you for All your answers you have provided to all of us, coders! We are learning from your experience and Thank you for sharing your knowledge with us with such comprehensive explanations!
Now back to your question, I am sorry I am not an expert yet but here is my rational- I would code it as Low MDM 99203 or 99213 because:
1. Dx is Low: pt has 2 minor s/s conditions: vaginal itching/burning AND urinary s/s
2. Data Limited: 2?:CST and PVR ( I googled them). I understand MD will bill for vaginal and urine cultures that he performed- it does not count.
3. Risk is Low: no meds, no procedures. Md didn't prescribe abx. He discussed if needed in the FUTURE.
Even if we had Data 3 or more, 2 problems are Low, Risk is Low= MDM Low.
It's going to be Fun to see other opinions! Christine, you are the Best and I always like your rationales in your posts. Thank you for being a mentor for so many of us.

 

[csperoni]

Thank you for the responses. I would love some additional feedback from others as well.
This current discussion is between my coding team and another department within my organization. Trying not to sway anyone with my personal opinion, the debate is between a low problem or a moderate problem. Everyone agrees the data is moderate and risk is low. It is simply about the level of the problem.
Opinion 1 - Moderate problem. Rationale: The provider states "UTIs vs OAB" making this an undiagnosed new problem with uncertain prognosis. The provider ordered additional testing to help determine a final diagnosis, but does not have one at the time of encounter.
Opinion 2 - Low problem. Rationale: Currently, patient "denies UTI symptoms today" and is unsure of her UTI history. None of the problems are specified as chronic problems, so consider them acute, which leads to acute, uncomplicated illness.

I 100% agree there is room for documentation improvement here, but that is being addressed separately. We are taking this documentation exactly as it stands.

 

[amyjph]

I am not on board with Opinion 1. Reason: AMA definition of: Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

If you are taking it exactly as it stands, I restate my earlier comment: From an auditor, it's a 3. The COPA is Low. I agree with Opinion 2.

What were the "Vaginal and urine cultures sent" results?

 

[MarissaLynne]

I have to agree with the person above me. The symptoms don’t fit criteria for “uncertain prognosis” to me. It may be undiagnosed but that does not mean you can’t code the symptoms until you have further diagnosis. I do not see how any of the listed symptoms could be “uncertain prognosis”. There is no high risk from these symptoms.

 

[csperoni]

I am not on board with Opinion 1. Reason: AMA definition of: Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

If you are taking it exactly as it stands, I restate my earlier comment: From an auditor, it's a 3. The COPA is Low. I agree with Opinion 2.

What were the "Vaginal and urine cultures sent" results?

The patient wound up with BV diagnosis and prescription called in, but this was not done at the time of the visit, and no documentation other than a task, so I cannot count that work.
Again, I appreciate the opinions, and welcome any additional!!