# need some guidance with a chart note



## ollielooya (Jun 7, 2010)

I must admit that I'm bewildered and enchanted by the EM process at the same time.  A friend of mine was asking for some help and I suggested we boldly submit it here which we are doing.  Would some of you kindly offer a breakdown for this NP visit?  I started to break it down myself and obviously fell apart very early into the note with the multiple issues so be kind, please. This is not a textbook question, but we're sure going to learn from it!!!!
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Mrs. X comes in today for a followup on her EGD. The EGD had a couple of significant findings.  One, she had a lot of retained food in her stomach which I think is probably diabetic gastroparensis.  In looking back through her chart she has been seeing an endocrinologist in Yuma and her last hemoglobin A1c was over 10, so she is obviously poorly controlled.

We talked about diabetic gastroparensis and the fact that once you have it, it never really goes away, but it will get worse if her blood sugars are not controlled.  The Reglan he does seem to be responding fairly well, so hopefully over time she will see some improvement.

The second issue is she did have some gastritis and biopsies positive for H. pylori.  We do have her on the appropriate antibiotic therapy and so far she is tolerating that well.  I wanted her to go ahead and finish this off.  I would probably stay on the Prevacid for a couple more weeks after that and then I would even suggest to her to try stopping the Prevacid particularly since she is on Plavix and it would be nice if she was not on any proton pump inhibitors at all.  I would continue through the Reglan indefinitely bcause I think she is going to have diabetic gastroparensis.

Now her husband also brought up a couple of other issues.  One of those issues he brought up was she is having some upper respiratory infection type symptoms, sore throat, cough, and a low-grade temp.  I told her if that keeps up or certainly if it gets worse she needs to see her primary care doctor.

The other issue is a little more concerning.  Apparantly she had an episode this weekend where she actually started slurring her speech and was even drooping a little bit, maybe her lip was drawn.  Now in looking at it today, it does look like she has a little droop of the left side of the face.

She very well could  have had a small stroke or possibly hyperglycemia or even hopoglycemia but because it was potentially a stroke, if that type of thing happens again she needs to go straight to the emergency room & get evaluated right away.

We will have her follow up with us on a prn basis
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How does a trained E/M coder decipher this particular note? 
Suzanne  E. Byrum, CPC


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## FTessaBartels (Jun 25, 2010)

*99214*

This is a good note from MDM perspective, but not from history or exam. In fact, there is *no exam *other than her remark that she looked at the patient's face and noted a slight droop on the left. 

This is really the kind of encounter that would have been perfect for counseling/coordination of care - IF - the provider had listed the total time spent, etc. 

Okay, let's work with what we have. 

I'm going to start with the *MDM*
*Problems:* 
new problem of respiratory infection w/o workup = 3 pt
new problem of slurred speech over weekend w/o work-up = 3 pt
established uncontrolled problem of diabetic gastroparensis = 2 pt
established stable problem of gastritis = 1 pt

*Data points*
Review or order EGD = 1 pt
Review or order labs = 1 pt
Getting history from husband = 2 pt
If I were certain that the provider personally reviewed the EGD films vs just looking at the report, then I'd give her 2 additional pts

*Risk*
One or more chronic illness (diabetic gastroparensis) with mild exacerbation (listed as poorly controlled) = moderate
Rx management (antibiotic therapy continued, stopping Prevacid) = moderate
Undiagnosed new problem (possible TIA) = moderate

So *MDM is HIGH * (4+ problem points; 4+ data points)

I already mentioned that there is no exam noted, other than observing the slight droop of face. 

Let's look at *history.*
*HPI* - you can count elements for each problem separately
Diabetic gastroparensis - Location (stomach) and modifying factors (responding to Reglan)
Gastritis - modifying factors (antibiotic therapy)
Resp Inf - Location (upper resp), severity (low-grade), Assoc Signs (sore throat & temp)

*ROS* - 
CV - she's on Plavix
Neuro - slurred speech this past weekend

*PMH* -
Had EGD
Had biopsies

*Social History*
Husband is with her

So you have 4+ HPI elements, 2-9 ROS, and PMH = *Detailed History*

This gives you a 99214 established patient visit - detailed history and high MDM.  

Just as a purely editorial comment -  I took this on as a sort of personal challenge and I probably spent over an hour disecting, figuring, reconfiguring, re organizing, adjusting my chart, etc to come up with this.  In a real audit, an auditor who would have to work this hard to verify a charge would NOT be very happy.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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