Coding Analyzer - Answer to Question 3
Hope everyone is having a great winter so far. The flu season is in full swing
at our office. I know you're all busy so let's press on through our examples.
Here is example patient #3 from the
Coding Analyzer
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.
So, how do we code
this? Let's step through the process again:
- The level of risk is
Low (uncomplicated injury).
- Data review is Minimal
- Number of Diagnosis/Treatment options is 6 (there are 6 patient instructions in
Treatment Plans) which brings our level of Decision Making only to Low.
Physical Exam is probably expanded problem focused ("limited exam
of the affected body area and other symptomatic/related organ system(s)")
History is problem focused (mainly because there is no review of
systems)
This brings the level of service to a 99213.
Now for the next
patient, instead of making an entire note, let's work with just the essentials:
"Patient with COPD on
home oxygen and 3 medications. He is stable and you make no changes to his
current therapy."
Let's assume we put a normal amount of information on the note. What would
be the level of service? (for a hint, look at last week's discussion).
How would you code this note and patient? Answers to follow next week.