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E/M Help

  1. #1
    Default E/M Help
    Medical Coding Books
    Visit Type: Scheduled follow-up
    Reason for visit (nurse documentation) 3mo pessary follow up appt and insert Femring
    CC: Pt to office for pessary check and insertion of femring. Pt has not been using her vagifem supp as directed.

    ROS: Constitutional: No fever, no chills, no weakness.
    ENMT: No decreased hearing
    Respiratory: No SOB, no cough
    CV: No chest pain, no palpitations, no peripheral edema
    GI: No nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
    GU: cystocele corrected with pessary. No dysuria, no urinary hesitancy
    Allergies: Cipro, Cyclobenzaprine, penicillin, sulfa drug
    Social History: Alcohol use: denied
    tobacco use: none
    Recreational drug use: denied

    Exam:
    Systolic BP: 155 mmHg HI
    Diastolic BP: 77 mmHg
    Heart rate on monitor: 57 bpm LOW
    BP Method: electronic measurements
    Weight: 64.410 kg
    Height Estimated in: 65 inch
    Weight lb: 141.7 lb
    BMI: 23.63
    General: Alert and Oriented. No acute distress.
    Neck: Supple, non-tender, no lymphadenopathy, no thyromegaly.
    Respiratory: Lungs CTA. Breath sounds are equal.
    GI: Soft, non-tender. Normal bowel sounds.
    GU: Normal genitalia for age. Vagina: Mucosa (Atrophy, dryness, vaginal introitus opening smaller due to atrophy. Not able to remove pessary without tearing vaginal opening today.)
    Integumentary: Warm, dry. Integumentary exam: Normal for ethnicity.
    Psychiatric: Alert and Oriented x4. Cooperative. Appropriate mood and affect.

    Diagnosis: Cystocele, Atrophic vaginitis
    Plan: Discuss using estrace cream to opening of introitus BID for next two weeks then follow up appt for removal of pessary and insertion of new femring. Pt educated on pessary care and douching and vaginal hygiene. Follow up sooner if problems.

    Provider coded as 99213 with primary diagnosis 627.3

    I'm reakky having more trouble pinning down the chief complaint, HPI, and correct diagnosis. Would this fall under some kind of contraceptive management code, or one of the diagnoses that were listed? Does it have enough for 99213?

  2. #2
    Default
    Hi Brandi,

    I agree with 627.3 and 99213

    Even though the CC states she's coming in for a Pessary check and has not been using the meds, the reason for the Pessary use is for the cystocele.
    On the exam the provider noticed vagnial atrophy and couldn't remove the pessary because of it. A new problem has presented and the provider recommends estrace cream and return in 2 weeks.

    I've come up with a PF HPI, EFP Exam and moderate MDM which ends up to 99213 by 1995 guidelines.

    I would not consider a contraceptive management code, because the provider is managing a presenting problem of vaginal atrophy.

    I hope this makes sense.

    Barbara
    The Oracle

  3. #3
    Default
    Quote Originally Posted by MJ4ever View Post
    Hi Brandi,

    I agree with 627.3 and 99213

    Even though the CC states she's coming in for a Pessary check and has not been using the meds, the reason for the Pessary use is for the cystocele.
    On the exam the provider noticed vagnial atrophy and couldn't remove the pessary because of it. A new problem has presented and the provider recommends estrace cream and return in 2 weeks.

    I've come up with a PF HPI, EFP Exam and moderate MDM which ends up to 99213 by 1995 guidelines.

    I would not consider a contraceptive management code, because the provider is managing a presenting problem of vaginal atrophy.

    I hope this makes sense.

    Barbara
    I appreciate it! Now that I look at this one, it's not as hard as I was making it - I do have another one, though - I should also mention that we only use 1997 guidelines, so that's what I have to score it by...let me know what you think about this note:

    Interval History:
    CC: Depression; Side effects of medication decreased. The course is improving. The effect on daily activities is a change in activity level (pt does better at work with mood and does not dread going home at night) and less tearful. No change in sleeping patterns. Associated symptoms characterized by no suicidal thoughts. Taking Lexapro as prescribed and tolerating. Anxiety decreased.

    ROS: Respiratory: No SOB
    Cardiovascular: No chest pain
    Gastrointestinal: Nausea, diarrhea resolving; noted initially when started lexapro but improving
    Allergies: NKA

    Social History: tobacco use - none

    Exam:
    Vitals: BP: 132/70
    Heart rate: 61 bpm
    Respiratory rate: 22
    Temperature oral: 97.4 degrees farenheit
    Oxygen saturation: 99%
    Weight: 242.5 lb
    Height: 70 inch
    Estimated BMI: 34.87
    General: Alert and Oriented. No acute distress.
    Respiratory: Lungs CTA. Breath sounds are equal.
    Cardiovascular: Normal rate. regualr rhythm. No murmur.

    [Then there are lab results listed from what appear to be routine labs, like a metabolic panel, lipid panel, and direct LDL. The only npotable results were high total cholesterol, triglycerides, and LDL. No psychiatric exam.]

    Impression/Plan:
    Diagnosis - depression
    Continue current dose lexapro; pt to f/u 6wks for f/u and to repeats LFT's given lipitor for HLP - pt has not started yet; told pt about $4 coupon for lipitor.


    My issues with this one:
    -The missing psych exam, since that's where the chief complaint is.
    -The lack of history on the hypercholesterolemia, and the fact that she didn't even list it as a secondary Dx.
    -I know for a fact that everything except for the vitals in the exam are EMR/EHR template defaults; I know there's no rule against that, but it still bugs me.

    I know that this should have scored higher than it will, because of the second condition that was barely documented. What I need help with is, do you think this scores a 99213 on 1997 guidelines? And what do you make of the missing psychiatric portion of the exam? Does it matter? Thanks!

  4. #4
    Default
    I agree with the issues you listed and would ask the provider to add documentation for the hypercholesterolemia. I mainly use the 1995 guidelines... so I'm kind of iffy to give an answer on this one.
    The Oracle

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