Coding Analyzer - Answer to Question 2

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);

History:
Chief Complaint: follow-up of Asthma.
History of Present Illness:
Patient is here for follow up of Asthma (stable). Symptoms currently well controlled. No side effects reported.

Past Medical History:
Problem List:
1. ASTHMA (493.90)
Medications:
1. Asmanex Twisthaler 220mcg Inhalation Powder TAKE 1 PUFF EVERY BEDTIME.
2. Proventil HFA Oral Inhaler TAKE 2 PUFFS AS NEEDED.
Allergies: NKDA.

Physical Exam:
Constitutional: Normal/negative.
ENT: Normal/negative.
Cardiovascular: Normal/negative.
Respiratory: Normal/negative.

Diagnoses:
1. Asthma (493.90) (Stable)

Treatment Plans:
1. Medication continued: Asmanex Twisthaler 220mcg Inhalation Powder TAKE 1 PUFF EVERY BEDTIME.
2. Medication continued: Proventil HFA Oral Inhaler TAKE 2 PUFFS AS NEEDED.
3. Follow-up: 3 Months
4. Keep peak flow diary bid.

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.

So, this asthma patient described above is a 99214.

If you have not yet completed the coding analyzer, take 5 minutes and click here.

Coding Analyzer - Question 3

Next patient: Sprained ankle

History:
History of Present Illness:
Here for complaints of falling and twisting her left ankle yesterday. Still able to walk but painful. Motrin seems to help.

Past Medical History:
Problem List:
Allergies: NKDA

Physical Exam:
Constitutional: Normal/negative.
Musculoskeletal: Left ankle with minimal point tenderness over medial maleolus. No swelling. Otherwise normal exam. Neuro intact.

Diagnoses:
1. PAIN IN JOINT ANKLE/FOOT (719.47)

Treatment Plans:
1. Rest, Ice, Compression, Elevation.
2. Take tylenol or motrin as needed.
3. If no improvement in 2-3 days, call or return to clinic.

How would you code this note and patient? Answers to follow next week.

Coding Growth Strategies

For those that are debating attending or purchasing a Coding Growth Strategies product, I've posted the first hour of the new 2011 Coding Growth Strategies here: Coding Growth Strategies Preview

Also, this year we are extending an 'alumni' discount. For all of you that have purchased or attended a seminar in the past, you can attend this year for the greatly reduced price of $200. Order on-line at www.codinggrowthstrategies.com or simply print and complete the seminar registration form attached to this email and send to our secure fax.