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Need clarification

  1. #1
    Default Need clarification
    Medical Coding Books
    I am trying to verify that the code our EMR system kicked out is legit. I actually think it should be coded a level 4 established, but I wanted to get feedback from my coding community:

    Patient X 09/19/1920
    Office/Outpatient Visit
    Visit Date: Mon, Mar 2, 2009 11:43 am
    Provider: Physician B (Supervisor: Physician A; assistant: Nurse A)
    Location: Cantonment Family Medicine PA

    Electronically signed by provider on 03/02/2009 02:41:20 PM
    SUBJECTIVE:

    CC:
    Mr. patient is a 88-year-old male. He presents with upper back pain. worse with coughing when coughing

    HPI:
    Mr. patient c/o thoracic back pain for about a week, with worsening pain over weekend. No injury or fall. Pain is improved with alleve and lortab. Worsened by coughing.
    Patient complains of upper back pain. The location is primarily in the mid thoracic spine. It does not radiate. He characterizes it as constant, severe, and sharp. He states that the current episode of pain started one week ago. He notes some pain relief with rest, NSAIDs, and narcotic pain medication. The pain worsens with coughing, moving.

    Also c/o worsening B/L LE edema not controlled w/ his usual dose of lasix 40mg BID.

    ROS:
    CONSTITUTIONAL: Positive for fatigue. Negative for chills, fever, unintentional weight gain or unintentional weight loss.
    EYES: Negative for blurred vision.
    E/N/T: Negative for ear pain, diminished hearing, tinnitus, frequent epistaxis, frequent rhinorrhea, periodontal disease, hoarseness and sore throat.
    CARDIOVASCULAR: Positive for pedal edema. Negative for chest pain, claudication, dizziness, orthopnea, palpitations, tachycardia or varicosities.
    RESPIRATORY: Positive for chronic cough, dyspnea and frequent wheezing. Negative for recent cough, exposure to tuberculosis, hemoptysis or pleuritic chest pain.
    GASTROINTESTINAL: Negative for abdominal pain, acid reflux symptoms, anorexia, abdominal bloating, dysphagia, constipation, diarrhea, heartburn, hematemesis, hematochezia, hemorrhoids, melena, nausea and vomiting.
    MUSCULOSKELETAL: See HPI
    NEUROLOGICAL: Negative for ataxia, dizziness, fainting, headaches, paresthesias, tremor and weakness.
    HEMATOLOGIC/LYMPHATIC: Negative for easy bruising and excessive bleeding.
    PSYCHIATRIC: Negative for anxiety, crying spells, depression, feelings of stress, anhedonia, personality change, difficulty concentrating, recreational drug use, sadness, sleep disturbance and suicidal thoughts.

    Current Problems:
    Cardiac angina
    CHF
    Chronic renal insufficiency
    Congestive heart failure, unspecified
    COPD
    COPD
    Coronary artery disease, of native coronary artery
    Fatigue
    Fatigue
    GERD
    Glucocorticoid deficiency
    Late effect of superficial skin injury
    Late effects of accidental fall
    Osteoarthritis involving several sites
    Peripheral vascular disease
    Pernicious anemia
    Type I diabetes, uncontrolled

    Allergies:
    No Known Drug Allergies.

    Current Medications:
    Humalog 100units/1ml Injection Inject as directed
    Doxazosin Mesylate 1mg Tablet Take 1 tablet(s) by mouth daily
    NitroQuick 0.4mg Tablets, Sublingual Dissolve 1 tablet(s) under the tongue may repeat every 5 minutes. Maximum of 3 doses in 15 minutes
    Lisinopril 2.5mg Tablet Take 1 tablet(s) by mouth daily
    Glipizide 10mg Tablets Take 1 tablet(s) by mouth qam before breakfast.
    Furosemide 40mg Tablets Take 1 tablet(s) by mouth bid
    Hydrocodone/Acetaminophen 7.5mg/500mg Tablet Take one tab po qid
    Amitriptyline HCl 25mg Tablet 2 po qhs
    Lantus 100units/1ml Injection 30 units are qhs
    Metoprolol 25mg Tablet take one tablet bid
    Prednisone 5mg Tablet Take 1 tablet(s) by mouth bid
    Ferrous Sulfate 324mg Tablets one tablet bid
    Metoclopramide HCl 10mg Tablet one tablet tid
    fish oil one tablet three times a day
    Combivent Oral Inhaler one puff bid
    Omeprazole 20mg Capsules, Extended Release one tablet bid

    OBJECTIVE:

    Vitals:

    Current: 3/2/2009 11:44:15 AM
    Ht: 68 inches; Wt: 234 lbs; BMI: 35.58
    T: 98.8 F (oral); BP: 112/55 mm Hg (left arm, sitting); P: 72 bpm (left arm (BP Cuff), sitting); R: 20 bpm

    Exams:
    PHYSICAL EXAM:
    GENERAL: well developed, well nourished, moderately obese; well groomed; wife present.
    E/N/T: EARS: external auditory canal normal; bilateral TMs are normal; OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx, including tonsils, tongue, and uvula are normal;
    RESPIRATORY: normal respiratory rate and pattern with no distress; no rhonchi; no wheezes;
    CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2; no cyanosis; 2+ pedal edema;
    MUSCULOSKELETAL: gait: slowed, unsteady, and ambulates with cane.; both sides of thoracic back w/ +TTP, no palpable step-off, no palpable crepitus. ROM exam limited by patients' overall difficulty with moving, difficulty ambulating.;
    NEUROLOGIC: mental status: alert; cranial nerves II-XII grossly intact;
    PSYCHIATRIC: appropriate affect and demeanor;

    ASSESSMENT:

    724.1 Upper back pain
    782.3 Pedal edema patient currently on Lasix 40mg BID----states he feels better when he doubles up on morning dose----requests new prescription to reflect this.

    ORDERS:

    Meds Prescribed:
    Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS #90 (Ninety) tablet(s) Refills: 6
    Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid #20 (Twenty) tablet(s) Refills: 1



    PLAN:

    Upper back pain

    RADIOLOGY: I have ordered thoracic spine xray to be done today. will call patient with results.

    Prescriptions:
    Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid #20 (Twenty) tablet(s) Refills: 1

    Pedal edema

    Prescriptions:
    Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS #90 (Ninety) tablet(s) Refills: 6


    CHARGE CAPTURE:

    Primary Diagnosis:
    724.1 Upper back pain

    Orders:
    99213 Office/outpatient visit; established patient, level 3

    782.3 Pedal edema


    ADDENDUMS:
    ____________________________________
    Addendum: 03/03/2009 06:33 AM - Physician A

    Reviewed and agreed. However, it may be a compression fracture, he is chronically on steroids for adrenal insufficiency and has multiple high risk medical problems.

    Physician A



    Thank you
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  2. #2
    Default
    On quick audit, I don't think 99213 is right.

    I come up with a complete history, comprehensive exam (based on 1995) and moderate medical decision making. Which translates into a 99215.

    I think part of the issue with your EMR may lie in the history part of it. For example, I pulled "wife" from the exam heading and used that for social history. If the provider doesn't click on a "heading" say for - social, family, or medical hx - does it still count it? With EMR it's tricky because the providers are the ones that have to be certain they put things in the right place or the software doesn't pick it up.

    The other thing is the EMR's primarily go off the 1997 guidelines, as expected, because they are much more precise. I'm thinking the EMR pulled an expanded problem focused history and exam based on the way the data was input and the way it extracts it.

    The EMR is only as good as the operator! Good luck! Hope this helps you.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default 99214 or 99215
    I went with a 99214.

    I see AR's point though about "wife present" and counting it for social history.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default
    That does help. I knew it couldn't be a level 3, but wasn't sure if it was enough to be a 5. I missed the part about the wife. I now have an audit tool to use to determine the level, so I'm going to run it through that spreadsheet and see what I come up with.

    Thank you for your help .
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

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