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jtb57chevy

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I'm getting 2 different opinions on the level of service for this office follow-up. I'd appreciate any feed back.

Thanks!

HPI: The patient presents to the office today for follow-up without complaints. She is doing well. The patient has a history of supraventricular tachycardia status post readiofrequency ablation. She has had no issues since the ablation.

Current Medications: The patient's current medications include Klonopin 0.5mg as needed.

Physical Exam: Blood Pressure: The patient's blood pressure is 120/60. Heart Rate: 96 Neck Exam: The neck is free of any bruits. Chest: The lungs are clear to aucsultation. Cardiac Exam: S1 and S2 ausculatated. Abdomen: Soft, pliable. Extremities: Pulses are present in bilateral lower extremities. There is no significant edema noted.

Diagnostic Impression:
1. Supraventricular tachycardia status post radiofrequency ablation - patient doing well.

Plan of Action:
1. The patient is to follow-up in one year or sooner if necessary.
 
I hope you have a chief complaint somewhere else because I don't really see one in the HPI.

Assuming that the follow-up is for the "supraventricular tachycardia status post readiofrequency ablation", I say it is a 99212.

Laura, CPC
 
well for MDM,
you have an established problem, stable ... 1 point
no data
for risk -- stable illness
so MDM is SF

for the exam,
using 95 DG's .... you have const, cardio, resp, gi ... the neck exam, extremities and edema are apart of cardio .... you could argue that since he examined 4 elements in the cardiovascular system, it is a detailed exam.

so, since it's a follow up, using MDM and the exam, you get 99212

also -- how long ago was the ablation? does it have a global period? if so, this would be a 99024, postop visit and not billable.
 
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How are you getting Low MDM? 1Dx pt, no data, low risk= straightforward

Laura, CPC
 
I also came up with a 99212, based on problem focused history, detailed exam and straight forward MDM (though only 2 of those 3 are needed).
I share Laura's concern that the chief complaint is not clearly stated until you get to the MDM section. I would advise the provider to expand on "follow-up" with something like "of supraventricular tachycardia" - this would be a teaching opportunity for future notes.
And as stated by ARCPC9491: check the dates to make sure it doesn't fall into any possible global period.
 
Karolina said:
I also came up with a 99212, based on problem focused history, detailed exam and straight forward MDM (though only 2 of those 3 are needed).
I share Laura's concern that the chief complaint is not clearly stated until you get to the MDM section. I would advise the provider to expand on "follow-up" with something like "of supraventricular tachycardia" - this would be a teaching opportunity for future notes.
And as stated by ARCPC9491: check the dates to make sure it doesn't fall into any possible global period.
Click to expand...

I'm a little confused. How do you get a detailed exam ? We use the 97 guidelines so i am not familiar with 95, if that's how you got it.
 
ARCPC9491 said:
well for MDM,
...

for the exam,
using 95 DG's .... you have const, cardio, resp, gi ... the neck exam, extremities and edema are apart of cardio .... you could argue that since he examined 4 elements in the cardiovascular system, it is a detailed exam.

...

I hope this works - I came to the same conclusion as ARCPC9491, my detailed exam is based on the 95 guidelines which simply state that you need 2 - 7 Organ Systems and/or Body Areas, extended exam of affected BA and other or related OS(s). In this case there are 4 items examined and the cardiovascular system exam was extended.
However, in this case the exam may be the highest of the 3 key elements, but doesn't impact the overall level.
Click to expand...
 
Somehow the quote in my prior post did not come through as a quote :confused:
The part above the "..." is quoted from ARCPC9491.
 
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