# What level would you code?



## TammyHF (Oct 1, 2008)

I have two new patients that I argue are 99202 but the doctor feels they are 99203. What would you code for E/M? Thank you for anhy sugestions you may have.

Tammy


*New Patient#1*

This 48 year old female presents today with a complaint of corns and calluses. Condition has existed for 10 years.  She indicates the problem location is plantar aspect of left foot and plantar aspect of right foot.  Severity of condition is 10 on a scale of 1-10 with 10 being the worst.  Pt states that the calluses are making her toes hurt. Pt states that walking and cold make her feet hurt worse. Pt is having her PCP Dr. XXXX shave them down and is taking Lortab for the pain.  

*Allergies: *No known medical allergies. 
*Medication History: Active: Lortab *(active).  
*Past Medical History:  Childhood Illnesses:* (+) chickenpox, (+) measles, (+) mumps, *Cardiovascular Hx: *(+) hypertension.  
*Past Surgical History: *Patient admits past surgical history of tubal ligation.  
*Social History: *Patient admits Tobacco Use. Cigarette, Patient denies Alcohol.  
*Family History: *Patient admits a family history of cancer associated with father, arthritis associated with mother.  
*Review of Systems:  Cardiovascular:* (+) chest pain, (+) high blood pressure.  

*Physical Exam: *BP Sitting: 172/111 HR: 97 Temp: 98.8 Height: 5 ft. 5.000 in. Weight: 136 lbs. BMI: 23 SS 7.5. Patient is a 48 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Oriented to person, place and time.  
*Cardiovascular:* Skin temperature of the lower extremities is warm to cool, proximal to distal. Dorsalis pedis pulses are 2 /4, Same as Left. Posterior tibial pulses are 2 /4, Same as Left. Capillary fill time is 3 seconds, Same as Left. No edema observed. Varicosities are not observed. 
*Skin:* Skin is warm and dry with normal turgor and there is no icterus.  Skin: Both feet, right 3rd metatarsal head and left 2nd metatarsal head.  Submet 3L and submet 3R demonstrates hyperkeratotic lesion.  
*Neurological:* Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal. 
*Musculoskeletal:* Both feet, right 3rd metatarsal head and left 2nd metatarsal head.  Gait and station examination reveals functional gait.  Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable. 

*Test Results:* No tests to report at this time,

*Impression: *Hyperkeratosis.  Hammertoe, digit 1, 2, 3, 4 and 5.  hyperkeratosis/ Callous.  paraesthesia.  abnormality of gait.  painful ambulation/ difficulty walking.  Hypermobility of the foot.  Enthesopathy.  pain joint of ankle or foot.  Deformity of the toe.  Hammer toe.  Metatarsalgia.  pain in limb.  

*Plan: Examined and educated,  *Both feet was Debrided 2-4 calluses as described above down to pink viable tissue. .  Treatment Plan is to treat this patient with conservative and restorative nonsurgical treatment to help alleviate the patient's symptomatology by utilizing some or all of the standard podiatric medical care- e.g.- palliation, orthotics, injections, physical therapy and the use of padding and strapping. 

Short term goals: Our plan is to decrease pain, and inflammation, improve ambulation and to allow the patient to return to normal activities, work, and long term weight bearing, pain-free and to prevent further disability.

Long term goals:  Our plan is for the patient to resume normal foot function and weight bearing, and to prevent surgical intervention.  We will reevaluate the patient's progress on a weekly or biweekly basis until symptoms complex subsides or is resolved.  Return to office in 3 week(s). Pt was dispensed Amerigel Blue and Dr. Jill reusable purple pads.  Pt is to call if any problems arise before next visit. 

*At this time I would recommend to have xrays and orthotics made for this patient.  We will try these conservative methods first.  If there is no resolution will look at more of a surgical solution.*

*New Patient #2*

This 53 year old male presents today for heel pain. Associated signs and symptoms include aching, edema location right, numbness, pain, pain with palpation and without palpation, pain with first steps in the morning, rash, swelling, tenderness and walking inability.  Prior history of this condition does not exist.  The patient has had no previous treatments for this condition.  Wants treatment now because of increased symptoms.  Condition has existed for 6-8 weeks.  He indicates the problem location is plantar aspect of right heel.  Patient indicates ambulation or shoegear pressure improves condition, shoe gear change, standing worsens condition and walking worsens condition.  Quality of the pain is described by the patient as 6, 7 and 8 on a scale of 1-10 with 10 being the worst, pulling, sharp, throbbing, tight, worse in the morning and uncomfortable.  He also presents stating that toenails 1-5 bilateral are brittle, discolored, elongated, painful with ambulation, sore, swollen and thickened.  Condition has existed for an extended duration.  He indicates the problem location is left foot and right foot locally.  Post-static dyskinesia present. Patient does not relate a history of trauma.  The patient's main occupation is a welder and he is a part time swim coach. The patient has difficulty with house and yard work.  Pt indicates his walking ability/tolerance is somewhat limited.  He participates with difficulty in house work and walking at work.  Pt presents today with heel pain in R foot. Pt states that he has had this pain for about 6-8 weeks now. Pt states that he works as a welder and a swim coach. Pt states that he at the pool for about 3-4 hours a day. Pt admits that when mowing the lawn he slipped on the curb. Pt states that the bottom of his heel hurts and then his toes will start to go numb. Pt states that he considers he broke it. Pt states that when he wakes up in the morning he can hardly walk to the bathroom and that in the morning is when it hurts the most. Pt states that he has put a form of support in his shoe to try to help with pain. Pt admits that he has not tried any stretches except for one time when his son suggested that he lean against a cabinet and stretch his foot out. Pt states that he has been taking Ibuprofen for pain but has a pretty high tolerance for pain. Pt states that when he wears shoe that it actually helps make his foot feel better. Pt states that his wife has pointed out several times that his foot was swollen. Pt admits that about 15 years ago when he was working at Coleman he dropped a barrel on his foot. 

*Allergies:* No known medical allergies. 
*Medication History: Active: simvastatin *(active).  
*Past Medical History:* Past medical history is unremarkable.  
*Past Surgical History:* No previous surgeries. 
*Social History:* Patient admits Alcohol.  Light, Patient denies Tobacco Use.  
*Family History:* Unremarkable. 
*Review of Systems:  Allergic / Immunologic:* (+) seasonal allergies.  

*Physical Exam: *Temp: 97.7 Height: 6 ft. 0.000 in. Weight: 194 lbs. BMI: 26 SS 10.5Patient is a 53 year old male who appears pleasant, his given age, in no apparent distress, well developed, oriented, well nourished, with good attention to hygiene and body habitus, breathing comfortably, with good attention to hygiene and body habits, alert and with a pleasant expression.  
*Cardiovascular: *Skin temperature of the lower extremities is warm to cool, proximal to distal. No edema observed. Erythema present.  Dorsalis pedis pulses are 2 /4, Same as Left. Posterior tibial pulses are 2 /4, Same as Left. Capillary fill time is 3 seconds, Same as Left. Varicosities are not observed. 
*Skin:* Inspection of plantar aspect of right arch shows dryness, ecchymosis, erosion, erythema, excoriations, lichenification and scaling.  *Skin:* Toenails 1-5 bilateral appear crumbly, discolored - yellow, discolored - dark, elongated, friable, painful with applied pressure, thickened, with dystrophic changes, with distal subungual debris, with subungual debris, with white superficial debris, Hypertrophic colored nails and Marked limited ambulation do to nail pain.  Right 1st toe sulcus, left great toe and right great toe demonstrates a lesion that is solitary, round, painful on lateral compression, hyperkeratotic, exhibiting thrombosed capillaries and exhibiting interruption of skin lines.  
*Neurological: *Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal. 
*Musculoskeletal:* Examination shows pain to palpation of plantar-medial/ medial tubercle of the calcaneus heel right, pain on palpation of plantar-central heel, pain to palpation of plantar-medial heel extending into arch and pain to palpation of plantar-medial heel extending distally along plantar aspect of foot right.  Heel pain elicited with palpation of posterior heel at Achilles tendon insertion right.  Heel pain elicited with palpation of posteriomedial plantar fascia insertion right.  Gait and station examination reveals coxa varum, early heel-off, functional gait, genu valgum, Pt with their knee extended and their midtarsal joint locked can barely get ankle to 90 degrees.  This is indicative of a functional equinus with no bony block at end ROM, and excessive pronation with hypermobile foot type seen.  Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable. Musculoskeletal: Examination of the posterior tibial tendon reveals abduction of forefoot at Chopart joint, loss of height of medial longitudinal arch, valgus deflection of the heel and Too many toe sign.  

*Test & X-Ray Results: * Foot and ankle X-rays were ordered and performed:  foot (3 views) right and Ordered and performed ultrasound of foot, see chart for report.  X-ray of the foot taken in 3 views reveals no evidence of fracture, tumor, infection and congenital abnormality, On the lateral view there are calcaneal spurs at site 2 and 4 R and Patient has partial obliteration of the sinus tarsi/ tarsal canal R.  Patient has Anterior, Medial and Plantar deviation of the talus R.  

*Impression:* Onychomycosis.  Unspecified nail disorder.  Hypertrophy of nail.  Onychocryptosis.  hyperkeratosis/ Callous.  unspecified skin disorder.  Wart/ Verucca.  hyperhydrosis.  Tinea Pedis.  Contact dermatitis.  Xerosis.  paraesthesia.  abnormaility of gait.  inflammation of fascia, ligament or muscle.  Hyperpronation.  muscle weakness.  painful ambulation/ difficulty walking.  Ligamentous laxity of the foot.  Hypermobility of the foot.  tenoynovitis of the foot.  short achilles tendon.  Enthesopathy.  Fasciitis.  Equinus deformity of foot and ankle.  achilles tendonitis/ bursa.  Plantar fasciitis.  Deformity of the toe.  Calcaneal spurs.  pain in limb.  

*Plan:Examined and educated,* Injected plantar fascia right.  Betadine prep was used to cleanse the area..  Ethyl chloride was used.  Area was injected with 3 cc mix of.  1% Lidocaine and 0.5% Marcaine.  Bethamethasone Acetate and Bethamethasone Sodium Phosphate per 3 mg.  Ultrasound was used for guidance of the needle. .  I explained that a steroid and local anesthetic injection usually decreases pain and inflammation.  I explained the possible complications including but not limited to infection, discoloration of skin, atrophy, steroid flare, and may increase blood sugars.  I explained that additional injections may be necessary.  I gave no guarantees regarding outcome. Pt submitted to injection.  I explained to the patient the etiology and treatment options for heel pain including injections, new shoegear, NSAIDs, rest, strappings and tapings, stretching exercises and PT modalities.  I discussed conservative care options that usually decreases symptoms 80-90% in 6 months.  I explained the need for a radiograph to r/o systemic arthritis and heel spur fracture.  Right great toe Skin biopsy taken as per protocol.  This is done by simple skin sample to r/o/in infection, mycotic infection, benign lesion and malignant lesion. 2 1.5mm Sample sent off to lab for analysis.  Debrided nails 1-5 b/l in length and thickness.  Right 1st toe sulcus, left great toe and right great toe Lesion(s) were Treated with cantharidin solution in colloid 0.7%. Mole skin was placed around the lesions to protect good skin and offload.  and Patient was dispensed Formaray.  This is to be applied to a Q-tip and used on affect wart tissue only every other day.  Patient was advised if this is used on healthy tissue it will over dry and crack skin..  I recommended patient be casted for functional orthoses.  I explained that orthoses may decrease pronation, decrease stretch on the plantar fascia, delay the formation of bunions, delay the formation of hammertoes, increase shock absorption and prevent surgery.  A patient education brochure was reviewed and given to patient.  I discussed the procedure for casting and fabrication of the devices.  The patient was asked to seriously consider this important treatment option.  I explained to the patient the etiology and treatment options for heel pain including injections, new shoegear, NSAIDs, rest, strappings and tapings, stretching exercises and PT modalities.  I discussed conservative care options that usually decreases symptoms 80-90% in 6 months.  I explained the need for a radiograph to r/o systemic arthritis and heel spur fracture.  Heel spur surgery was discussed with the patient, including risks and complications such as delayed wound healing, exacerbation of arthritis, failure to relieve the problem, infection, numbness, prolonged stiffness and recurrence of the spur.  Alternatives treatments including conservative care was discussed.  The patient and I reviewed the types of shoes they should be wearing, my recommendation includes having the patient look for new shoes, having their feet measured before trying on new shoes and generally the best time of the day for a shoe fitting is the afternoon.  The following were recommended and explained to the patient: Home ROM and strengthening exercises, Achilles tendon stretching and Progressive use and challenging of the affected part allowing for mild discomfort during activity.  Weight bearing as tolerated is encouraged.  Also recommended stretching before activities, intermittent use of ice after the activity, and occasional supplementation with an NSAID of choice.  Attempt to "work through" the symptoms is advised, as long as symptoms are not increasing.  Severe symptoms should lead to a period of rest followed by resumption of exercise and strengthening.  Appropriate warnings and instructions are emphasized.   Plan is unchanged from last visit.  Icing and stretching home going instructions were given to patient.  Return to office in 3 week(s). Patient was scanned for orthotics.  Patients insurance plan was contacted and attempted verified for coverage of medically necessary equipment.  They are covered by their insurance plan. Since these devices are covered, patient would like to think about ordering devices until a later time or next visit. .  Pt was dispensed Forma Ray, Pumi Bar, Biofreeze and Crocs.  Lidex ointment and gel 60 grm tube 2 refills.  Patient is to call if any further problem arises before next visit. Pt was advised continue with stretching as instructed. Pt was advised that when a predetermination was given, we would call and have him come in to dispense DME items. Pt is covered for orthotics but needs a predetermination. Pt was advised to use Lidex ointment on the bottom of his feet, and the gel in between his toes. 


*At this time I feel it is medically necessary to dispense L4396 night splint, L1902 air heel, and L3000 x2 custom orthotics to help reduce nocturnal and post nocturnal pains in the plantar arch and heel.  This will be an attempt to negate surgical intervention at this time.*


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## rryder1963 (Oct 1, 2008)

*A quick glance...*

New Pt #1  99202

New Pt #2 99203 could be argued for


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## ARCPC9491 (Oct 1, 2008)

Patient #1 - 

On quick audit, I get 99203

History:
HPI: Location, Duration, Severity, Modifying Factor = 4 HPI Elements
PFSH: 3/3
ROS: Cardio and Allergic - I pulled NKDA for the extra ROS
Overall History: Detailed
Exam:
For 1997 DG's, I get 10 Bullets (Expanded Problem Focused)
For 1995 DG's, I get 6 Organ Systems. Documentation supports "Detailed"
MDM:
New problem, with work up
Order Xrays
Risk: Low (Minor Surgery, no risk factors or Physical Therapy)

(I don't know much about podiatry medicine, but if Amerigel blue is a prescription, you'd have a moderate risk - however, the history and exam would still dictate the level because you have to have 3/3 for new patients)

For the debridement of calluses, you could code 11056 as well.  The procedure documentation, to me, is a bit weak, your provider should have elaborated more.


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