Hey everyone! Let's jump in and continue on our Coding Analyzer challenge. With this patient we address the issue of disease progression.
Here is our note from last week (question #2 from the Coding Analyzer);
How did you code this? Let's analyze the separate parts and see:
First, as always we identify the nature of the presenting problem:
Number of diagnoses or treatment plans: 4 = high
Amount of data review: Minimal
Risk: Moderate (chronic problem with mild disease progression)
Satisfying our 2 out of 3 requirement gives us a
Moderate amount of medical decision making.
Physical exam is extensive exam of the affected organ system (Respiratory) and any other related organ systems. This is a Detailed physical exam.
His level of History is not contributory since the above 2 items satisfy the coding requirements for a 99214.
Wait a minute you say? How is this a chronic problem with mild disease progression? He's not any worse than he was before! His asthma is stable!
That's right. But disease progression is not a measure of how far the symptoms
have progressed compared to the last visit. It is a measure of how far his
disease has progressed compared to the disease. For example, you
can have stable asthma in any of the following types:
Needs intermittent albuterol occasionally.
Needs maintenance medication in addition to prn
albuterol (Inhaled corticosteroid).
Needs multiple maintenance medications (ICS, Singulair,
and abluterol).
Needs chronic oral steroids in addition to the above.
Any of the above asthmatics could be "stable". However there is a big difference
between the exercise-induced asthmatic and the one taking daily prednisone. That
difference is clarified in Medical Decision Making under the Risk category.
Next patient: Sprained ankle
How would you code this note and patient? Answers to follow next week.
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