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What Level would you code?

  1. #1
    Default What Level would you code?
    Medical Coding Books
    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


    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??

  2. #2
    north seattle wa
    I get the same as you do. Your physicians don't waste any ink/keystrokes do they!

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