# New pt office code discrepancy



## renifejn (Oct 22, 2008)

This case is up on emuniversity and there are some discrepancies....before you look on their website for the answer--what do you get?


A New Office Patient

CC: The patient is here to establish care.

HPI:  The patient is a 67 YOWM with NIRDM for 10 years. He states his sugars have been stable recently. He also has hyperlipidemia whch has been effectively managed with statin therapy and HTN which has been easy to control on routine medications. In addition, he has documented CAD which has been quiescent with no active chest pain.

MEDICATIONS: As reviewed in the medication list.

ALLERGIES: NKDA

ROS/PFSH: Reviewed using a questionnaire. Note is made of intermittent dyspnea with exertion and history of CAD s/p CABG in 2002. For more details, please refer to the ROS/PFSH portions of today's intake form located in this chart.

PHYSICAL EXAM.
CONSTITUTIONAL:  NAD, somewhat obese white male.
Vitals: BP 144/85, HR 84, RR 22
EYES: Anicteric sclerae; no lid-lag or proptosis .
ENMT: Unremarkable.
CARDIOVASCULAR: RRR, no MRGs, normal PMI.
RESPIRATORY:  Bii-basilar crackles; no wheezes.
GI:  Unremarkable.
MUSC:  Unremarkable except for 1+ bipedal edema.
PSYCH: A&OX4 with a cordial affect.
SKIN: Unremarkable.
NEURO: Unremarkable.

LABORATORY INFORMATION:  Shows a BUN of 22 with a creatinine of 1.8, sodium 141, potassium 4.8, bicarbonate 21, calcium 8.3, phosphorous 3.9, hemoglobin of 12.7, HGBA1c 7.7, LDL 74

IMPRESSION: 

Ischemic cardiomyopathy with moderate symptoms of CHF. 
Sub-optimally controlled NIRDM. 
Stage III CKD with GFR of 40.2 mls/min. 
Stable hyperlipidemia. 
Sub-optimally controlled HTN. 
PLAN:

D/C METFORMIN. 
Start GLUCOTROL 5 mg PO BID. 
Increase LISINOPRIL to 40 mg PO BID. 
Increase LASIX to 40 mg PO BID 
Increase KCL to 20 mEq PO BID. 
Echocardiogram this week. 
RTC next week with renal profile, CBC, spot urine prot/creat.


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## LLovett (Oct 23, 2008)

If I was auditing this I would say it is a 99202. I have not looked on the other web site to see what they have. I do not give credit for those unremarkables in the exam.

Laura, CPC


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## renifejn (Oct 23, 2008)

Thanks...that's what I came up with too, but the webiste says 99204.  There were a bunch of comments but they "mysteriously" disappeared.  Wonder if they'll change it...


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## ARCPC9491 (Oct 24, 2008)

Dr Jensen coded it as 99204 and counted "unremarkables" as credit in the exam - thus giving him comprehensive (8+ organ systems based on 95)

I actually posted a comment questioning why he'd credit the unremarkables and I see, too, that it is mysteriously gone.

I completely disagree with counting unremarkable.  Unremarkable is not the same as negative.  Unremarkable means it doesn't pertain, so I didn't do it or also "deferred". My physicians agree with not using this term and if they do, they know they don't get credit.  Plain and simple, you didn't do it, you don't get credit.


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