# new to auditing and would appreciate a second opinion on visit note



## SHobbs (Nov 26, 2012)

I have come up with an Expanded Problem Focused History, Comprehensive Examination, and Low Complexity Medical Decision Making for a 213.  If anyone could review and let me know if this is correct I would greatly appreciate any and all expertise. 

Vital Signs:
Time: 		01:44 PM
Weight: 		331 lbs 4 oz
Height: 		67"
BMI: 		51.87
Temperature: 	98.1 F (Oral)
Waist Circumference: 	56 inches
BP: 		140/70(Left Arm)(Sitting)
Pulse: 		87(Apical)(Sitting)
Respiration: 	16
Oxygen: 		96(Room air)

Time: 		01:55 PM
BP: 		130/78(Right Arm)(Sitting)

Chief Complaint:

Patient is here for yearly blood work.
CHIEF COMPLAINT: Patient states he is here for a chief complaint of rash .

Current Medication:
1 Albuterol 0.83 Mg/ml Solution 2.5 Mg /3 Ml (0.083 %)  nebulizer every 4 to 6 hrs prn 
2 Flexeril 10 Mg Tablet  Take 1 three times a day 
3 Flovent Hfa 220 Mcg Inhaler Mcg/actuation  2 puffs bid 
4 Proair Hfa 90 Mcg Inhaler Mcg/actuation  2 puffs qid and prn 
5 Tramadol Hcl 50 Mg Tablet  Take 1 twice daily 
6 Medrol 4 Mg Dosepak  use as directed 
7 Nasonex 50 Mcg Nasal Spray Mcg/actuation  2 sprays each nostril qd 
8 No Otc Meds.  
9 Vesicare 5 Mg Tablet (Other MD)  Take 1 daily 

Allergy/Adverse Reaction:
No Known Allergies

Social History:
Social history was reviewed & updated on Nov 21, 2012 by , MA.
 currently smokes one pack per day and has been smoking for 30 year(s) .
He denies alcohol use.
He denies recreational drug use.
Patient is married.
Caffeine intake consists of He denies drinking caffeinated coffee., soda. He drinks 12 cans of soda per day., He denies drinking caffeinated tea.

Family History:
Family history reviewed and unchanged on Nov 21, 2012 by , MA. Postive Family History: (+) CAD in father, (+) glaucoma in father, (+) Heart Disease in father and (+) hypertension in father and in mother.

Medical History:
Reviewed and unchanged on Nov 21, 2012: allergies, current medication list, medical history, by , MA.
He has not been hospitalized or visited the ER in the last 12 months. Patient has seen a specialist since last visit on or around May 2012 ( Dr.). Does not see a specialist at this time.

Collaborative Tracking: Preventative Screenings: Has had an preventative eye exam on Jul 30, 2012. Patient has not had a preventative dental exam in the last year.
Asthma.
Sleep apnea (obstructive).
Carpal tunnel syndrome. Degenerative joint disease.
Lumbar disc disease. Removal of 4 discs in back.
Arthritis.
Surgeries Procedures: tumor in upper back 1989.

HPI:
44 year 3 month age old patient is here for Patient was cutting trees and was hauling brush and poison ivy vines and now has a rash. Respiratory: He denies shortness of breath, cough, pain with deep breath, wheezing or any other complaints related to respiratory system. Cardiovascular: He denies chest pain, palpitations, fainting spells, pedal edema or shortness of breath.

ROS:
See HPI.

Current medications reviewed. Patient claims he is compliant with medications and has experienced no side effects. Past medical history, family history, and social history reviewed.
General: (-) fever, (-) chills, (-) fatigue, (-) weakness, (-) changes in appetite or weight.
Skin: See HPI.
Eyes: (-) visual changes, (-) eye pain, (-) eye discharge, (-) double or blurred vision.
Nose and Sinuses: (-) nasal congestion, (-) postnasal drip, (-) nosebleeds, (-) sinus problems.
Respiratory: (-) cough, (-) shortness of breath, (-) wheezing.
Cardiac: (-) chest pain, (-) irregular heartbeat, (-) palpitations, (-) shortness of breath.

Examination:
Skin: Linear rash on arms and chest but does not having any open and weeping areas.
Lymphatic: No lymph node enlargement or tenderness noted. There is no evidence of acute or chronic lymphedema.
ENT: Bilateral ear canals clear, TM's appropriate in color with good cone of light. Nasal mucosa pink, no sinus tenderness. Oral mucosa pink, moist, without lesions. Posterior pharynx pink, moist, without exudate.
Neck: Supple. No thyromegaly or nodules. No lymphadenopathy.
Respiratory: Lungs are clear to auscultation. No wheezes, rales, or rhonchi noted. Respirations are equal and unlabored.
Cardiovascular: Heart rate is regular. S1 and S2 present with no audible murmurs noted. PMI is non displaced. Peripheral pulses intact, 2+ bil. No pedal edema noted.
Gastrointestinal: The abdomen is soft, non-tender without rebound or guarding. Normoactive bowel sounds are heard in all quadrants. No palpable masses or hepatosplenomegaly noted. No hernia observed.
Musculoskeletal: There is no evidence of joint pain, tenderness or deformity. Full Range of motion intact to all major joints.
Neurologic: Alert and oriented X 3. Cranial nerves II-XII are grossly intact.

MMSE/PHQ:
PHQ: PHQ2: Over the last 2 weeks, how often have you been bothered by any of the following problems?.
Feeling Down, Depressed, or Hopeless? No.
Little Interest or Pleasure in Doing Things? Yes PHQ9: Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things: 1 (Several Days).
Feeling down, depressed, or hopeless: 0 0 (Not at all).
Trouble falling or staying asleep, or sleeping too much: 0 0 (Not at all).
Feeling tired or having little energy:3 (Nearly every day) 3.
Poor appetite or overeating: 0 (Not at all) 0.
Feeling bad about yourself -- or that you are a failure to have let yourself or your family down: 0 (Not at all) 0.
Trouble concentrating on things, such as reading the newspaper or watching television: 0 (Not at all) 0.
Moving or speaking so slowly that other people could have noticed. Or the opposite -- being so fidgety or restless that you have been moving around a lot more than usual: 1 (Several Days) 1.
Thoughts that you would be better off dead, or of hurting yourself in some way: 0 (Not at all) 0.
Total Score = 5 (5) If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?: Not difficult at all.

Diagnosis:
692.6      Dermatitis due to Plants 305.1      Tobacco Use Disorder V65.42      Counseling on Tobacco and/or Substance Abuse 

Prescription:
1 Prednisone 10 Mg Tablet  SIG: 1 po tid for 5 days 1 daily for 2 days  QTY: 17.00 

Changed/Discontinued Medication(s): 
   Discontinued By Patient: MEDROL 4 MG DOSEPAK

Care Plan:
Patient Education/Counseling: BMI over normal range for age and gender. Provided Choose My Plate for nutrition and exercise education. Instructed patient to establish realistic weight loss goals. Ideal BMI range discussed. Diet and Nutrition:
Patient was assessed for his readiness to make changes in lifestyle (diet) for disease prevention and/or long-term disease management.
Does patient eat at least 2-1/2 cups of fruits and vegetables each day? Patient plans to start doing this sometime in next month (Pre-Preparation). Let's Eat For Health of IT (Choose My Plate) information discussed and/or provided. Discussed how fat, carbohydrates and protein are processed within the body. Education regarding healthy food choices and portion size provided. Exercise and Physical Activity: Effects of exercise on various body systems explained to patient. (ie: blood pressure, blood glucose, cardiovascular system). Instructed to participate in some form of exercise.
Patient was assessed for his readiness to make changes in lifestyle (exercise) for disease prevention and/or long-term disease management.
Is patient physically active for 30 or more minutes for 5-7 days a week?Patient plans to start doing this sometime in next month (Pre-Preparation) Be Physically Active My Way (Choose My Plate) information discussed and provided. TOBACCO CESSATION: Tobacco cessation counseling provided.
Patient was assessed for his readiness to make changes in lifestyle (smoking cessation) for disease prevention and/or long-term disease management.
Has patient quit smoking/never smoked? Patient is not interested in doing this and has no plans to change (Pre-Contemplation Stage) Quitline Fact Sheet given to patient, which includes 1-800-QUIT-NOW (1-800-784-8669) quit line Ready to Quit-Five Steps to Quit Smoking-given to patient. Self Management goals discussed.. Tips for Staying Quit provided. Medication list to aid in smoking cessation given to Edgar.
MEDICATIONS: Continue all current medications Instructions given to patient on risk, benefits and possible side effects of new prescription medication. Proper method of taking discussed. Patient-Family understands instructions for new medication(s)..
FOLLOW-UP: 3 month(s). Return to clinic as needed. Return sooner if the condition changes, worsens, or does not resolve. If condition worsens, call 1-877-733-5824 to schedule an appointment with your primary care provider, or after hours, call on-call provider at 660-827-8235. Go to ER if worsening. All questions were addressed. Patient/caretaker appears to clearly understand and is comfortable with careplan. Discussed treatment plan and expected course..
REFUSAL: Patient refuses Influenza, Pneumovax  immunization(s) at this time. Risks associated with unimmunized status discussed and questions answered. OTHER: Pt is aware that he is due for a dental exam. I will not offer Tdap today.

Educational Handouts:
(1) Medication List for Stop Smoking
Medication List for Stop Smoking
(2) Quitline Fact Sheet
Quitline Fact Sheet
(3) Ready to Quit-Five Steps
Ready to Quit-Five Steps
(4) Tips for Staying Quit
Tips for Staying Quit
(5) Be Physically Fit
Source: Department of Health and Senior Services and U.S. Department of Agriculture
http://www.choosemyplate.gov
(6) Lets Eat for the Health of it 
Source: Department of Health and Senior Services and U.S. Department of Agriculture
http://www.choosemyplate.gov

Followup:
3 Month(s)


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## LLovett (Dec 3, 2012)

*EMR gone wild!*

I agree with you on the EPF history and Comp exam, for MDM I am coming up with moderate. Dermatitis new problem no work up 3pts, tobacco abuse established stable 1pt, and Rx management. So I would go with a 99214.

Laura, CPC, CPMA, CEMC


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## SHobbs (Dec 3, 2012)

Can you help me understand why the dermatitis with new problem get 3 points?


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## AprilSueMadison (Dec 5, 2012)

Using the table of risk on an E/M auditing sheet, a new problem is categorized as moderate.  If you look at the points on an auditing sheet, that new problem is assigned three points.  

I use the information on E/M University website to help.


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## Ruth Carter (Dec 5, 2012)

*new auditor second opinion*

The rash is a new problem as well as prescribing prednisone and that is also in the moderate for the MDM.


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## kparkhurst (Dec 21, 2012)

I would caution using 99214. Remember, medical neccessity is the overarching criterion for code selection. Although you may technically be able to reach a level 4 - medical necessity here clearly is a low level problem and would be a 99213.


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## SHobbs (Dec 21, 2012)

kparkhurst said:


> I would caution using 99214. Remember, medical neccessity is the overarching criterion for code selection. Although you may technically be able to reach a level 4 - medical necessity here clearly is a low level problem and would be a 99213.



I had thought the same thing and was not comfortable with taking it up to a 99214 so kept at 213.  Thanks!


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## prmiller (Dec 27, 2012)

I agree with the medical necessity comments.  However, the red flags that I see in this note are that under the chief complaint it also states that the patient is here for yearly blood work.  If they are having yearly blood work done, there is probably a condition that would warrant the need for much of the other information in this note.  That other condition should also then be noted in the assessment, but it is not.  This is a perfect time to do some education with your provider on why it is so important that they document everything.  If the other problem were documented, then you have no issues with billing a 99214.  Because it is not, you are limited to 99213 and they have just lost a significant amount of money for what would have taken them seconds to record.


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## snowbird100 (Dec 28, 2012)

*Would preventive medicine apply?*

Is it possible to code this as a Preventive Medicine Service.  Thanks for your imput. I graduated & have my CPC but I have so much to learn.  Thanks


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