# E/M Help



## btadlock1 (Apr 16, 2011)

Visit Type: Scheduled follow-up
Reason for visit (nurse documentation) 3mo pessary follow up appt and insert Femring
CC: Pt to office for pessary check and insertion of femring. Pt has not been using her vagifem supp as directed.

ROS: Constitutional: No fever, no chills, no weakness. 
ENMT: No decreased hearing
Respiratory: No SOB, no cough
CV: No chest pain, no palpitations, no peripheral edema
GI: No nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
GU: cystocele corrected with pessary. No dysuria, no urinary hesitancy
Allergies: Cipro, Cyclobenzaprine, penicillin, sulfa drug
Social History: Alcohol use: denied
tobacco use: none
Recreational drug use: denied

Exam:
Systolic BP: 155 mmHg HI
Diastolic BP: 77 mmHg
Heart rate on monitor: 57 bpm LOW
BP Method: electronic measurements
Weight: 64.410 kg
Height Estimated in: 65 inch
Weight lb: 141.7 lb
BMI: 23.63
General: Alert and Oriented. No acute distress.
Neck: Supple, non-tender, no lymphadenopathy, no thyromegaly.
Respiratory: Lungs CTA. Breath sounds are equal.
GI: Soft, non-tender. Normal bowel sounds.
GU: Normal genitalia for age. Vagina: Mucosa (Atrophy, dryness, vaginal introitus opening smaller due to atrophy. Not able to remove pessary without tearing vaginal opening today.)
Integumentary: Warm, dry. Integumentary exam: Normal for ethnicity.
Psychiatric: Alert and Oriented x4. Cooperative. Appropriate mood and affect. 

Diagnosis: Cystocele, Atrophic vaginitis
Plan: Discuss using estrace cream to opening of introitus BID for next two weeks then follow up appt for removal of pessary and insertion of new femring. Pt educated on pessary care and douching and vaginal hygiene. Follow up sooner if problems. 

Provider coded as 99213 with primary diagnosis 627.3

I'm reakky having more trouble pinning down the chief complaint, HPI, and correct diagnosis. Would this fall under some kind of contraceptive management code, or one of the diagnoses that were listed? Does it have enough for 99213?


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## MJ4ever (Apr 16, 2011)

Hi Brandi,

I agree with 627.3 and 99213

Even though the CC states she's coming in for a Pessary check and has not been using the meds, the reason for the Pessary use is for the cystocele.
On the exam the provider noticed vagnial atrophy and couldn't remove the pessary because of it. A new problem has presented and the provider recommends estrace cream and return in 2 weeks.

I've come up with a PF HPI, EFP Exam and moderate MDM which ends up to 99213 by 1995 guidelines.

I would not consider a contraceptive management code, because the provider is managing a presenting problem of vaginal atrophy.

I hope this makes sense.

Barbara


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## btadlock1 (Apr 17, 2011)

MJ4ever said:


> Hi Brandi,
> 
> I agree with 627.3 and 99213
> 
> ...



I appreciate it! Now that I look at this one, it's not as hard as I was making it - I do have another one, though - I should also mention that we only use 1997 guidelines, so that's what I have to score it by...let me know what you think about this note:

Interval History:
CC: Depression; Side effects of medication decreased. The course is improving. The effect on daily activities is a change in activity level (pt does better at work with mood and does not dread going home at night) and less tearful. No change in sleeping patterns. Associated symptoms characterized by no suicidal thoughts. Taking Lexapro as prescribed and tolerating. Anxiety decreased.

ROS: Respiratory: No SOB
Cardiovascular: No chest pain
Gastrointestinal: Nausea, diarrhea resolving; noted initially when started lexapro but improving
Allergies: NKA

Social History: tobacco use - none

Exam:
Vitals: BP: 132/70
Heart rate: 61 bpm
Respiratory rate: 22
Temperature oral: 97.4 degrees farenheit
Oxygen saturation: 99%
Weight: 242.5 lb
Height: 70 inch
Estimated BMI: 34.87
General: Alert and Oriented. No acute distress.
Respiratory: Lungs CTA. Breath sounds are equal.
Cardiovascular: Normal rate. regualr rhythm. No murmur.

[Then there are lab results listed from what appear to be routine labs, like a metabolic panel, lipid panel, and direct LDL. The only npotable results were high total cholesterol, triglycerides, and LDL. No psychiatric exam.]

Impression/Plan:
Diagnosis - depression
Continue current dose lexapro; pt to f/u 6wks for f/u and to repeats LFT's given lipitor for HLP - pt has not started yet; told pt about $4 coupon for lipitor.


My issues with this one:
-The missing psych exam, since that's where the chief complaint is.
-The lack of history on the hypercholesterolemia, and the fact that she didn't even list it as a secondary Dx. 
-I know for a fact that everything except for the vitals in the exam are EMR/EHR template defaults; I know there's no rule against that, but it still bugs me. 

I know that this should have scored higher than it will, because of the second condition that was barely documented. What I need help with is, do you think this scores a 99213 on 1997 guidelines? And what do you make of the missing psychiatric portion of the exam? Does it matter? Thanks!


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## MJ4ever (Apr 18, 2011)

I agree with the issues you listed and would ask the provider to add documentation for the hypercholesterolemia. I mainly use the 1995 guidelines... so I'm kind of iffy to give an answer on this one.


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