# Need clarification



## KristieStokesCPC (Mar 3, 2009)

I am trying to verify that the code our EMR system kicked out is legit. I actually think it should be coded a level 4 established, but I wanted to get feedback from my coding community:

Patient X 09/19/1920 
Office/Outpatient Visit
Visit Date: Mon, Mar 2, 2009 11:43 am
Provider: Physician B (Supervisor: Physician A; assistant: Nurse A)
Location: Cantonment Family Medicine PA

Electronically signed by provider on  03/02/2009 02:41:20 PM                         
SUBJECTIVE:

CC: 
Mr. patient is a 88-year-old male.  He presents with upper back pain.  worse with coughing when coughing 

HPI: 
Mr. patient c/o thoracic back pain for about a week, with worsening pain over weekend.  No injury or fall.  Pain is improved with alleve and lortab.  Worsened by coughing.  
Patient complains of upper back pain.  The location is primarily in the mid thoracic spine.  It does not radiate.  He characterizes it as constant, severe, and sharp.  He states that the current episode of pain started one week ago.  He notes some pain relief with rest, NSAIDs, and narcotic pain medication.  The pain worsens with coughing, moving.  

Also c/o worsening B/L LE edema not controlled w/ his usual dose of lasix 40mg BID. 

ROS: 
CONSTITUTIONAL:  Positive for fatigue.   Negative for chills, fever, unintentional weight gain or unintentional weight loss.  
EYES:  Negative for blurred vision.  
E/N/T:  Negative for ear pain, diminished hearing, tinnitus, frequent epistaxis, frequent rhinorrhea, periodontal disease, hoarseness and sore throat.  
CARDIOVASCULAR:  Positive for pedal edema.   Negative for chest pain, claudication, dizziness, orthopnea, palpitations, tachycardia or varicosities.  
RESPIRATORY:  Positive for chronic cough, dyspnea and frequent wheezing.   Negative for recent cough, exposure to tuberculosis, hemoptysis or pleuritic chest pain.  
GASTROINTESTINAL:  Negative for abdominal pain, acid reflux symptoms, anorexia, abdominal bloating, dysphagia, constipation, diarrhea, heartburn, hematemesis, hematochezia, hemorrhoids, melena, nausea and vomiting.  
MUSCULOSKELETAL:  See HPI 
NEUROLOGICAL:  Negative for ataxia, dizziness, fainting, headaches, paresthesias, tremor and weakness.  
HEMATOLOGIC/LYMPHATIC:  Negative for easy bruising and excessive bleeding.  
PSYCHIATRIC:  Negative for anxiety, crying spells, depression, feelings of stress, anhedonia, personality change, difficulty concentrating, recreational drug use, sadness, sleep disturbance and suicidal thoughts.  

Current Problems: 
Cardiac angina 
CHF 
Chronic renal insufficiency 
Congestive heart failure, unspecified 
COPD 
COPD 
Coronary artery disease, of native coronary artery 
Fatigue 
Fatigue 
GERD 
Glucocorticoid deficiency 
Late effect of superficial skin injury 
Late effects of accidental fall 
Osteoarthritis involving several sites 
Peripheral vascular disease 
Pernicious anemia 
Type I diabetes, uncontrolled 

Allergies: 
  No Known Drug Allergies. 

Current Medications: 
Humalog 100units/1ml Injection Inject as directed 
Doxazosin Mesylate 1mg Tablet Take 1 tablet(s) by mouth daily 
NitroQuick 0.4mg Tablets, Sublingual Dissolve 1 tablet(s) under the tongue may repeat every 5 minutes. Maximum of 3 doses in 15 minutes 
Lisinopril 2.5mg Tablet Take 1 tablet(s) by mouth daily 
Glipizide 10mg Tablets Take 1 tablet(s) by mouth qam before breakfast. 
Furosemide 40mg Tablets Take 1 tablet(s) by mouth bid 
Hydrocodone/Acetaminophen 7.5mg/500mg Tablet Take one tab po qid 
Amitriptyline HCl 25mg Tablet 2 po qhs 
Lantus 100units/1ml Injection 30 units are qhs 
Metoprolol 25mg Tablet take  one tablet bid 
Prednisone 5mg Tablet Take 1 tablet(s) by mouth bid 
Ferrous Sulfate 324mg Tablets one tablet bid 
Metoclopramide HCl 10mg Tablet one tablet tid 
fish oil one tablet three times a day 
Combivent Oral Inhaler one puff bid 
Omeprazole 20mg Capsules, Extended Release one tablet bid 

OBJECTIVE:

Vitals: 

Current: 3/2/2009 11:44:15 AM
Ht: 68 inches;  Wt: 234 lbs;  BMI: 35.58
T: 98.8 F (oral);  BP: 112/55 mm Hg (left arm, sitting);  P: 72 bpm (left arm (BP Cuff), sitting);  R: 20 bpm

Exams: 
PHYSICAL EXAM: 
GENERAL: well developed, well nourished,  moderately obese;  well groomed; wife present. 
E/N/T: EARS: external auditory canal normal;  bilateral TMs are normal;  OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx, including tonsils, tongue, and uvula are normal; 
RESPIRATORY: normal respiratory rate and pattern with no distress; no rhonchi; no wheezes; 
CARDIOVASCULAR: normal rate; rhythm is regular;  normal S1; normal S2; no cyanosis; 2+ pedal edema; 
MUSCULOSKELETAL: gait: slowed, unsteady, and ambulates with cane.;  both sides of thoracic back w/ +TTP, no palpable step-off, no palpable crepitus.    ROM exam limited by patients' overall difficulty with moving, difficulty ambulating.; 
NEUROLOGIC: mental status: alert;  cranial nerves II-XII grossly intact; 
PSYCHIATRIC: appropriate affect and demeanor; 

ASSESSMENT: 

724.1	    Upper back pain 
782.3	    Pedal edema patient currently on Lasix 40mg BID----states he feels better when he doubles up on morning dose----requests new prescription to reflect this. 

ORDERS: 

Meds Prescribed: 
  Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS  #90 (Ninety) tablet(s) Refills: 6 
  Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid  #20 (Twenty) tablet(s) Refills: 1 



PLAN: 

 Upper back pain 

RADIOLOGY:  I have ordered thoracic spine xray to be done today.  will call patient with results. 

  Prescriptions: 
  Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid  #20 (Twenty) tablet(s) Refills: 1 

 Pedal edema 

  Prescriptions: 
  Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS  #90 (Ninety) tablet(s) Refills: 6 


CHARGE CAPTURE: 

Primary Diagnosis: 
724.1	    Upper back pain 

                   Orders:
                    99213  Office/outpatient visit; established patient, level 3  

782.3	    Pedal edema 


ADDENDUMS:  
____________________________________
Addendum: 03/03/2009 06:33 AM - Physician A

Reviewed and agreed.  However, it may be a compression fracture, he is chronically on steroids for adrenal insufficiency and has multiple high risk medical problems.

Physician A



Thank you


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## ARCPC9491 (Mar 4, 2009)

On quick audit, I don't think 99213 is right.

I come up with a complete history, comprehensive exam (based on 1995) and moderate medical decision making. Which translates into a 99215.  

I think part of the issue with your EMR may lie in the history part of it. For example, I pulled "wife" from the exam heading and used that for social history. If the provider doesn't click on a "heading" say for - social, family, or medical hx - does it still count it? With EMR it's tricky because the providers are the ones that have to be certain they put things in the right place or the software doesn't pick it up. 

The other thing is the EMR's primarily go off the 1997 guidelines, as expected, because they are much more precise. I'm thinking the EMR pulled an expanded problem focused history and exam based on the way the data was input and the way it extracts it.

The EMR is only as good as the operator! Good luck! Hope this helps you.


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## FTessaBartels (Mar 5, 2009)

*99214 or 99215*

I went with a 99214.

I see AR's point though about "wife present" and counting it for social history. 

F Tessa Bartels, CPC, CEMC


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## KristieStokesCPC (Mar 5, 2009)

That does help. I knew it couldn't be a level 3, but wasn't sure if it was enough to be a 5. I missed the part about the wife. I now have an audit tool to use to determine the level, so I'm going to run it through that spreadsheet and see what I come up with.

Thank you for your help  .


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