What Level would you code?

ARCPC9491

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I have a note that looks exactly like this. The ROS and Exam points are completely mixed up and I think that's why I'm getting confused but I need reassurance.;)

CC: primary hypothyroidism

HPI: f/u on synthroid. C/o wt gain despite diet/exercise.

Thyroid Size: N
Energy: Improved
Moods/Sleep: N
Temp. Intolerance: -
Palpitations/CV: -
Gyn/Resp/GI: -
Thyroid Pain: -
Weight Change: + 5 lbs
Eyes: N
Memory: N
Diaphoresis -
Hair/Nails/Skin: N
M/S/Neuro: N

Exam:

Vitals: 120/76 BP, HR 72, HT 66, WT 151
General: NAD
Eyes: PERRL
Thyroid: No nodules
Neck: Lymphatics: No LAP
CV: RRR
Chest/Abdomen: CTA Abd. Soft
Neuro, MS, Reflexes, Tremor: -

A/P: Hypothy - check labs, if TSH > 2.0 will increase dose.


---------------------
CC: Documented.
HPI: Diet/Exercise/Synthroid - Mod Factor 1 HPI Element
PFSH: None Documented?

To me, Thyroid Size, Mass Effect, Thyroid Pain belongs to the Thyroid Exam.
Moods/Sleep could be Neuro and Pysch - both? or one or the other? Energy and Temp. Intolerance relate to endocrine, Palpitations CV, Gyn/Resp/GI as they are, Weight Change consitutional, Eyes as eyes, memory neuro, diaphoresis neuro?, hair/nails/skin as is, m/s/neuro as is.

So that to me would be for ROS would be:
1- Neuro 2- Pysch 3-Endocrine 4-CV 5-GYN 6-Resp 7-GI 8-Eyes 9-Constitutional 10-Skin - Complete ROS

For Exam, we would have:
1 Bullet - 3 Vital Signs
2 Bullet - General Appearance
3 Bullet - Examination of Thyroid
(No credit for palpating lymph nodes in neck - must be 2 areas right?)
4 Bullet - Auscultation of Lungs
5 Bullet - Examination of Abdomen
6 Bullet - Auscultation of Heart


MDM: Est prob, worsening, order labs, 1+ chronic illness w/ mild exacerbation

Since our history isn't very well documented, I would use Exam and MDM to come up with EPF Exam and Moderate MDM making the overrall level a 99213??

What level would everyone else come up with?? Can anyone explain my questionable areas??:confused:
 
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