Stuck between a 2&3. Opinions please?!

renifejn

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Diagnosis: JDM
Other diagnoses: none
Social History (grade, PE, activities, school days missed): Sr in HS, good grades, ful pe, badmitton, tennis, golf, missed 4 days due to pneumonia


SPECIFIC COMPLAINTS/PROBLEMS ILLNESS:
none


NEW FAMILY HISTORY:
none


REVIEW OF SYSTEMS:


SKIN: Normal
EYES: Normal
EARS: Normal
NOSE: Normal
MOUTH: Normal
RESP: Normal
CARDIO: Normal
GI: Normal
MUSCULOSKELETAL: Normal
NEURO: Normal
GU: Normal
Nighttime Urination: No
MENSES: Yes Time Between Periods 28 days
ENDOCRINE: Normal
PSYCH: Normal
LYMPHATIC: Normal


Eye Exam: Yes Date of Last Eye Exam 1/09
General appetite: good
Calcium intake in diet? Yes Servings per day? 3
Sunscreen use? Yes SPF # 45
Pain: No
Stiffness: None
Presence of Infection: No
Infectious episodes since last visit: Yes Number of episodes: 2 Location of infection(s): Pneumonia-treated with a Z-Pak
Functional Status: Normal function (able to attend school, keep up with friends)


PHYSICAL EXAM:
Blood pressure 121/77, pulse 80, resp. rate 20, height 151.2 cm, weight 40 kg.
BSA: Body surface area is 1.37 meters squared.
GENERAL APPEARANCE: Normal
SKIN: ABNORMAL: Vitiligo on back
HEAD: Normal
EYES: Normal
EARS, NOSE, THROAT, MOUTH: Normal
NECK: Normal
RESPIRATORY: Normal
CARDIOVASCULAR: Normal
ABDOMINAL: Normal
GENITOURINARY: Tanner Stage: 3
MUSCULOSKELETAL: Normal
NEUROLOGIC: Normal
PSYCHIATRIC: Normal


Skin Involvement: Absent or resolved completely
Distribution: None
Neck Flexor Weakness: No Grade: 5
Difficulty clearing scapula (abdominal weakness) No
Can do sit-up with: 3=behind head
Upper prox. muscle weakness 5 No
Lower prox. muscle weakness 5 No
Gower's sign: Unassisted
Abnormal gait No
Difficulty swallowing No
Nasal speech No
Spine Expansion: 15-22cm
Vasculitis: No
Severe Vasculitis: No
Gotrons' Papules: Absent
Calcification: Absent
Peripheral fat atrophy: Absent
Acanthosis Nigricans: Absent
Raynaud's: Absent
Loss of ROM No
Status of JDM: No Rash or Weakness


Meds: On Immunosuppressive therapy


VISIT IMPRESSION:
JDM-stable exam, no active arthritis


VISIT PLAN:
Lab evaluation today
 

Karolina

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Messages
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Boston, MA
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Is this an established patient visit? Looks like it. In that case I can see how you are in between. You need two of three and based on history and exam you would get a 99213. However, MDM should be a driving factor - and the MDM really is straight forward in my opinion (which supports the 99212). How much of the history and exam was truly medically necessary? Every so often it is possible that medical necessity is higher than the medical decision making and it would be fair to base the code on history and exam. If a lot of the information is documented because the template prompted for it, it might be overdocumented. Do you have similar cases to compare the note to and figure out if all the history and exam was needed to provided appropriate care?
 
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