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E/M Level - Upon my review of the chart below

  1. Default E/M Level - Upon my review of the chart below
    Medical Coding Books
    Upon my review of the chart below I have justiy for New Patient Level 4, However Dr. says base on pt Dx this should be New pt L3. Any comment appreciated ..
    Note: PFSH all three are valid the per their auditing department None is valid because iss was address.

    Initial Orthopaedic Assessment
    Ref src: Previous Patient
    Employment: Fashion

    Vital Signs
    Height: 82 inches


    CC: L-sided lower back pain

    HPI: has been having some LBP over the last mos - this weekend was doing an exercise class and got some LBP during the class pain got worse over the next few days. Getting some L buttock pain - achy and stiff in the LB - No LE paresthesias.
    Better w salon pas patches, lying flat.
    Worse w sitting. No prior PT or imaging done.
    PMH: anxiety
    PSH: none
    FH: none

    MOBIC 7.5 MG TABS (MELOXICAM) 1 tab by mouth 2 times daily for 7 days then as needed

    Allergies: No Known Allergies
    Pregnant? N
    Pain site: LB worse
    scale: 8
    Living environment: apartment

    Alcohol use: Y
    Average drink(s) per day: <1

    Review of Systems
    Constitutional: No Complaints
    ENT: No Complaints
    EYE: No Complaints
    Gastrointestinal: No Complaints
    Cardiovascular: No Complaints
    Genitourinary: No Complaints
    Neurological: No Complaints
    Psychiatric: No Complaints
    Endocrine: No Complaints
    Hemato/Lymph: No Complaints


    RLE pulses: present and palpable
    LLE pulses: present and palpable

    Appearance: well developed, well nourished, no acute distress

    Nodes: no LE edema

    Inspection: normal

    Appearance Normal
    IR/ER: negative

    Lumbar Spine/Pelvis
    Range of motion: pain w flex and ext and SB L
    Somatic: normal
    Palpation: + TTP L SI jt

    Special Tests
    Slump: negative
    IR/ER: negative
    SI joint: positive L
    SLR: negative

    Right Lower Extremity
    Range of motion: normal ROM
    Musc strength/tone: normal tone and strength

    Left Lower Extremity
    Range of motion: normal ROM
    Musc strength/tone: normal tone and strength, 4/5 hip abd/ext

    Coordination: normal coordination
    Reflexes: 2+, symmetric, no pathological reflexes
    Sensation: intact

    Mental Status Exam
    Orientation: oriented to time, place, and person
    Mood and affect: no alteration in mood or affect

    Problems including current update:


    Impression BACK PAIN, LUMBAR (ICD-724.2)

    trial of mobic 7.5 mg two times daily,xray LS spine r/o DDD, f/u 4-5 wks if still pain MR

    Patient instructed for potential side effects and complications of prescribed/administered medication(s) and agrees to consume and/or receive it/them., Start Physical Therapy, Reviewed HEP, Continue HEP, Ice area 10 min. on 10 min. off for 30 min.

    Services & Orders
    X-ray exam, lumbar spine AP/lateral/oblique [CPT-72010]

    Barriers: None
    Teaching method: discussion with patient
    Pt significant other(s) can verbalize/return demonstrate instructions.

    Thank you.

  2. #2
    Columbia, MO
    I agree with your provider, based on the presenting problem I get a level 3 as well. He does not document a gyn exam nor a pap screening, why is that in the impression? The MDM is moderate and I get detailed on the exam.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    I just noticed something above that makes it ESTABLISHED patient rather than new.

    Direct Quote from the post:
    Initial Orthopaedic Assessment
    Ref src: Previous Patient
    Employment: Fashion
    Emphasis added.
    I could be wrong but I see that and think not New.

  4. #4
    Default new pt
    The last post is correct...........this looks like it could be an est pt cpt not New. Provided that patient had been seen by this dr in the past 3 years. If that's the case 99214. If the patient hasn't been seen in the past 3 years then 99203

  5. #5
    Columbia, MO
    Maybe it means she was referred by a previous patient? That is how I understood it

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    Thanks all for your input, however I am still having a challenge understanding why New pt 99203 and not a New pt 99204? Will appreciate some more insight.
    This is a new patient never seen before, Ref src is Referral source came from a previous patient (Not the patient was a previous patient). Does presenting problem over ride or a major contributor in the credit given then documentation credits obtain? Patient came in with back pain scale of 8 and was given Prescription drug management with the following:

    HPI =4> elements
    PSFH = 3 areas
    ROS= 10 System

    8 Organ systems

    New prob w/addition work up - Xray order, Prescription drug management.

    Impression: is lower back pain

    Any input for a better understanding, what or where I am giving incorrect credits.

  7. #7
    Ann Arbor, Michigan
    Default Debra Hirshfield, RHIT, CPC
    I would not count none in the PMH or PSH. The response of none doesn't indicate that a question was asked or answered. This would count as one in the PFSH which would bring the overall history to a detailed.

  8. #8
    Daytona Beach, FL
    I also would not count the None for the social and family history. I would give 1 point however for social history as it does mention the patient lives in an apartment - but this would still leave the history at a detailed level.

    For the exam, I am only counting 7 organ systems: contitutional, eyes, cardio(pulses and LE edema), skin, muscularskeletal, neuro and psych - so I would say that it is detailed, not comprehensive. I would not give credit to the lymph system as under that heading he mentioned LE edema and nothing about the lymph nodes.

    So with a detailed history and exam and moderate MDM this would be a 99203.

    Hope that helps.
    Jodi Dibble, CPC

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