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Challenge to all E/M experts. What level is this???

  1. #1
    Default Challenge to all E/M experts. What level is this???
    Medical Coding Books
    First off no comments on whether this is me cheating on my home work, or bring home work for you to do for me. I already billed this out. Just curious to see what kind of different opions I get on this.

    Question

    1) what level

    2) would this documentation qualify for a consult.








    A patient has had a several year history of paresthesias and pain in the distribution of the median nerve and also a retrograde pain symptomatology. She has had a diagnosis of carpal tunnel syndrome made and has been treated with non-steroidal anit-steroidal anit-inflammatory medication and also wrist splints which appear to give her signifcant relief when she is wearing the wrist splint. However, it is getting progressively more sever and she is desirous of undergoing some form of treatment other than the present splint.

    PHYSICAL EXAMINATION: On examination she presents as a well-developed, well-nourished female. Exam of the upper extremity demonstrates a full range of motion of the cervical spine and right shoulder, however, there is some restricted motion at the right wrist. A Tinel's sign is absent over the median nerve and a Phalen's test is also not positive over the right median nerve.

    On this basis it is felt that even though she has symptoms that are consistent with carpal tunnel syndrome, because these cannot be reproduced with the various testing maneuvers, it is important that she be further evaluated with a median nerve conduction study of the median nerve at both wrists and an upper extremity EMG in order to insure that the source of symptoms is coming from the carpal tunnel and not from the cervical spine.

  2. #2
    Default
    Quote Originally Posted by daniel View Post
    First off no comments on whether this is me cheating on my home work, or bring home work for you to do for me. I already billed this out. Just curious to see what kind of different opions I get on this.

    Question

    1) what level

    2) would this documentation qualify for a consult.








    A patient has had a several year history of paresthesias and pain in the distribution of the median nerve and also a retrograde pain symptomatology. She has had a diagnosis of carpal tunnel syndrome made and has been treated with non-steroidal anit-steroidal anit-inflammatory medication and also wrist splints which appear to give her signifcant relief when she is wearing the wrist splint. However, it is getting progressively more sever and she is desirous of undergoing some form of treatment other than the present splint.

    PHYSICAL EXAMINATION: On examination she presents as a well-developed, well-nourished female. Exam of the upper extremity demonstrates a full range of motion of the cervical spine and right shoulder, however, there is some restricted motion at the right wrist. A Tinel's sign is absent over the median nerve and a Phalen's test is also not positive over the right median nerve.

    On this basis it is felt that even though she has symptoms that are consistent with carpal tunnel syndrome, because these cannot be reproduced with the various testing maneuvers, it is important that she be further evaluated with a median nerve conduction study of the median nerve at both wrists and an upper extremity EMG in order to insure that the source of symptoms is coming from the carpal tunnel and not from the cervical spine.
    With the info given, you couldn't bill this as a consult. At best a 99213.

    Just my opinion

    Roxanne

  3. #3
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    Greeley, Colorado
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    This is a 99202 or 99213...it is not a consult because there is no reference of the patient having been referred for consultation and no note of a response being sent to a referring provider. You have an expanded problem focused history (1ROS and no PFSH), expanded problem focused exam and moderate level MDM.
    Lisa

  4. #4
    Default
    I would say that this would qualify for a 99213. It does not support a consult according to the guidelines, there is no reference to referring physician or that a reply was sent to anyone. Looking at the documentation I see an EPF History and exam with Moderate MDM.

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