1995 guidelines
Marcia,
I hear your frustration.
First let me address you problem w/ ROS ... Just because there isn't a separate paragraph heading marked ROS doesn't mean that you never have an ROS. Let's look at THIS note.
Chief complaint: preventive visit, Hx of DM
HPI - Severity: "fair glucose level"
ROS - musculoskeletal - wear diabetic shoes
I'll admit I'm stretching it here by counting the diabetic shoes as MS for ROS, but you get the idea. This is enough for an EPF history.
NOW ... even more important to your understanding, you do not even need the history on this note to get to a 99213.
Using the 1995 guidelines your exam has 3 systems:
Cardiovascular - pedal pulses
Skin - rashes/lesions
Musculoskeletal - exam of nails
This equals an EPF exam under the 1995 guidelines.
Now let's tackle the MDM:
Problem points: I get a total of 4
1 pt for DM established, stable
3 pt for tinea pedis (new problem, no workup)
Data points: none
Risk: Moderate due to Rx for Lotrisone
For an established patient you only need to meet 2 of the 3 key elements of the E/M. With an EPF exam and moderate MDM you easily get 99213.
I agree with NOT coding hammertoe. It's not even mentioned anywhere. But you should definitely be coding the diabetes.
Also, since I don't code for podiatry I'm not sure about this ... but is the nail trimming separately reportable for a DM patient? (I'm thinking maybe 11721?)
Finally, Marcia ... you are right that the podiatrist needs to improve his/her documentation. A few simple phrases would go a long way to allowing the doctor to capture the charges for the kind of service s/he is actually providing. At least once a year you should have your patients complete a patient history questionaire ... this could include the ROS and past medical/family/social history. The doctor would review, sign and date this form, and then could reference it in the dictation.
For DM patients, I think you might want to have some notation of when the patient last saw his/her PMD (or endocrinologist). Some statement as to whether this is Type 1 or Type 2, controlled or not controlled.
I hope this helps. I've also sent you a private message.
F Tessa Bartels, CPC, CEMC