# audit question - complicated by gastroischisis



## rcbaker (Oct 1, 2009)

please help me: the patient is an 18 month old girl initially seen in this clinic on december 1st. there were long standing concerns about her overall development. she was born at 34 weeks. her neonatal course was complicated by gastroischisis. here initial hospitalization lasted approximately 1 month.

she has shown significant deficits in all of her gross motor skills, and there were concerns about dysconjugate gaze. at the time of her initial examination, microcephaly was also noted. she was alert and smiled briefly. she had good head control. she was unable to maintain a sitting position. she had a decrease in muscle mass and increase in tone diffusely. this was more noticeable in her lower than her upper extremities. she was hyperreflexic. she had crossed adductor response and extensor plantar response as well.

since then, the patient has made improvement in her language and motor skills. currently, she says several words that are easily understandable at home. she smiles, she is friendly, and she is interactive. she continues to have significant gross motor difficulties. she now sits much better than she did previously, and she will pull to stand. she is engaged in a therapy program.

the patient had an mri performed about a week ago. it was available for review. it showed significant white matter loss both in the frontal and posterior head regions. there were some areas of cystic encephalomalacia.

the results of the mri were explained to the patient's parents. the patient's history and her neurological examination and her mri are consistent with non progressive process that probably is a consequence of her preterm birth and acute illness at that time. her overall language and social skills today are in the normal range, particualary when adjusted for gestational age. she continues to have significant motor deficits. plans were made for the patient to be seen in followup in the neurolog clinic.

doctor selection e/m 99214. How can i audit this?


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## LLovett (Oct 1, 2009)

If this is the note I am confused.

Was this visit just to go over results of the MRI? I would say this needs to be based on time because this is a bunch of history, no clear cut HPI, no exam, and I am coming up with Low complexity MDM.

I don't see anyway to get a 99214 out of this. I don't see time so I am guessing it wasn't documented and is not an option.

This looks more like a summary letter to another provider, not an indvidual visit. I would not feel comfortable billing anything based on this.

Sorry not much help here,

Laura, CPC, CEMC


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## rcbaker (Oct 1, 2009)

*audit question*

thanks Laura


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## FTessaBartels (Oct 1, 2009)

*99213*

This is an established patient, so you only need 2 out of three (History, Exam, MDM).

I'll go in reverse and start with MDM.

I get *Low MDM*
2 problem points for 2 established problem, stable (1 pt EACH for language and motor deficits)
1 Data point for MRI review (possibly 2 pts, hard to tell if doctor actually was looking at the films or just the report)
Low Risk for Stable chronic illness

We have no exam, so now we look at history.
We need an *EPF history* (chief complaint, 1-3 HPI, problem pertinent ROS)
Chief Complaint: We have documented microcephaly (concerns over developmental delay are implied ... and I think the real reason for this follow-up visit)
HPI:  Location: Head (microcephaly, head control)
ROS:  Musculoskeletal (documentation re ability to sit and pull-up to standing), 

The doctor really makes us work for this (in terms of auditing) ... but I can justify a 99213.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## rcbaker (Oct 2, 2009)

thanks


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