Wiki 99213 or 99214?-dysmetria or ataxia

[justjc]

Doc thinks this is 99214 but I disagree. Is "no findings" acceptable documentation for ROS? Using 1995 guidelines. Would appreciate any help.

CC: Worsening headache
HPI: Pt reports headache slightly improved since last visit. Headache on & off. When it occurs, headache all over head. Pain described as aching and is 6 on scale of 1-10. Pt would feel nauseated during headache. Denies vomiting. Still sensitive to noise & light. Pt feels dizziness most of time, describes as lightheaded. No changes w/pain on neck. Pt takes Topamax 50 mg 1 tab q hs- not every night. Not yet started on Topamax BID. Pt experiencing back pain for the past 2 weeks. Rates pain as 9 on scale of 1-10. Started Flexeril PRN yesterday per PCP. Notices Flexeril helps. Feels soreness on arms & legs.
PFSH: Documented on initial consult
ROS:
HEENT: No findings
Chest: No findings
Cardiac: No findings
Abdomen: No findings
Urinary Tract: No findings
Genital: No findings
Orthopedic: No findings
Neurologic: Headaches
Psychological: No findings
Endocrine: No findings
VITALS: Wt-154lbs, BP-140/88, Pulse-75, Respiratory Rate-16 breaths/min
PHYSICAL EXAM:
Appearance: Normal
Skin: No lesions, rashes or pigmentations
Head: Atraumatic nomocephalic
Eyes: Pupils equal, round and react to light & accomodation. Sclera is clear no discharge or tearing
Neck: Supple, thyroid normal, no adenopathy
Chest: Clear to ascultation
Cardiac: Normal rate and regular rhythm; no murmurs
Extremities: No cyannosis or clubbing, peripheral pulses are palpable, no orthopedic abnomalities
NEURO EXAM:
Mental status exam: Normal
Speech: Fluent & coherent speech
Motor: Bulk is normal. Strength testing throughout normal. Tone is normal.
Sensory: Sensation to light touch, pinprick and cold temperature is intact
Coordination: No tremors. No dysmetria or ataxia
Station and Gait testing: Station is normal. Routine & tandem gait testing normal
Romberg test: Normal
ASSESSMENT:
Chronic daily headaches
Migraine UNSP W NTRC MGR STD
Cervicalgia
Back Pain, Low
Iron Def, Anemia
PLAN: Topamax 50mg for chronic & recurrent migraines. D/C Elavil. Discussed various possible triggers for headaches and to avoid to prevent possible recurrences. Follow up in 6 weeks. Neck, mid & low back pain due to multilevel spondylosis. Recommend physical therapy 2x/wk for 1 month

 

[LLovett]

99214

A detailed history only requires 2 ROS. There are multiple systems reviewed under the HPI portion of the note.

Based on history and exam this is a 99214.

CC: Worsening headache
HPI: Pt reports headache (location) slightly improved since last visit. Headache on & off (timing). When it occurs, headache all over head. Pain described as aching (quality) and is 6 on scale of 1-10 (severity). Pt would feel nauseated (ROS GI)during headache. Denies vomiting. Still sensitive to noise & light. Pt feels dizziness (ROS Neuro) most of time, describes as lightheaded. No changes w/pain on neck . Pt takes Topamax 50 mg 1 tab q hs- not every night. Not yet started on Topamax BID. Pt experiencing back pain for the past 2 weeks. Rates pain as 9 on scale of 1-10. Started Flexeril (Past Hx)PRN yesterday per PCP. Notices Flexeril helps. Feels soreness on arms & legs (ROS MS).


Hope this helps,

Laura, CPC, CPMA, CEMC

 

[jewhipke]

I would code as 99214

 

[MikeEnos]

I agree, you definitely have enough there for a 99214 just based on the exam and MDM. Even with your question about the ROS, you have enough for an extended ROS just in the HPI paragraph. To answer your question about his ROS, documenting that there are "no findings" is exactly the same as saying that the systems are "negative" so I would give credit.

 

[justjc]

Thank you all for your replies. That makes sense. I guess one of the other reasons I was unsure was because this patient had been to the same doctor 3 times within about 3 months for the exact same problem. The note I posted the other day seemed like a follow up as it stated the patient's headache (presenting problem) improved from last visit. In addition the ROS, Phys exam & Neuro exams are exactly the same as the previous visit about 1 month earlier. Does it matter if the visit is a follow up?