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:

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.

Coding Analyzer - Question 4

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.