Hi
Would the below note be considered 99213? If so, what elements are missing or inadequate to meet the standard for 99214? This provider is a specialist and the system coder puts everything at 99213. We are wondering if it is coding correctly.
Thank you
1. Back pain. 2. Neck pain.
HPI:
Lumbar Spine/Lower Back:
Patient is here today for evalutaion of his back pain. He stated that the pain radiates into his groin and his legs and he has numbness in his legs and feet. Patient also stated that he has pain in his neck that radiates into his arms. He stated that he has numbness in his arms and hands as well. On a scale of 0-10 with 0 being the least amount of pain and 10 being the worst amount of pain, he stated that today his pain level is an 8. He recently had to work on his car and was lying on the concrete. he had a hard time getting back up and ever since then, he has been having more neck pain and arm pain. that was 1 week ago.
Medications: OxyContin 40 mg 1 tab(s) bid, Norco 325 mg-10 mg 1 tab(s) q 4 H, Neurontin 400 mg 1 cap(s) qhs
Allergies: Morphine.
Objective:
Vitals: BP sitting 146/93, Pulse sitting 64, RR 18, Temp 97.7, Ht 71, Wt 305, BMI 42.53.
Examination:
Lumbar Spine/Lower back:
Reflexes: Normal. Sensation: Within normal limits. Provocative Tests: .. Neurologically Stable: No upper motor neuron signs are seen. Location: Lower back. ROM: Within normal limits, Some discomfort is present at extremes of the range of motion.
Cervical Spine/Neck:
ROM: of neck and both upper extremities appear to be within normal limits., Some discomfort is present at extremes of the range of motion.. Location Neck. Reflexes: normal. Sensations: Within normal limits. Provocative Tests: are not performed today. Neurologically Stable: No upper motor neuron signs are seen.
Items reviewed:
Radiology Films not reviewed. Radiology Films not reviewed. Medical records reviewed. Medical records reviewed. Narcotic drug policy is in chart was reviewed with patient today . Narcotic drug policy is in chart was reviewed with patient today . Home exercise program was reviewed and discussed with the patient. Home exercise program was reviewed and discussed with the patient. Current work restrictions are not applicable as patient is not working. Current work restrictions are not applicable as patient is not working.
Assessment:
Assessment:
1. LUMBAR DISC DEGENERATION - 722.52 (Primary)
2. CERVICAL DISC DEGENERATION - 722.4
3. Chronic pain syndrome - 338.4
4. PAIN (SHOULDER) - 719.41
5. POST LAMINECTOMY SYNDROME - 722.83
6. Radicular syndrome of lower limbs - 724.4
7. DISC DIS NEC/NOS-LUMBAR - 722.93
8. Low back pain - 724.2
9. Cervical arthritis - 721.0
10. Radicular syndrome of upper limbs - 723.4
11. LUMBAR STENOSIS - 724.02
Plan:
1. Cervical arthritis
I advised patient to give it another couple weeks for the neck to recover from the stress of him laying on the concrete to fix his car. If at that time he is still not improving, I will get an MRI. Medications are refilled today. NDP is renewed.
2. Others Refill OxyContin tablet, extended release, 40 mg, orally, 60, 1 tab(s), bid, 30 day(s), Refills 0 ; Refill Norco tablet, 325 mg-10 mg, orally, 120, 1 tab(s), q 4 H, 30 day(s), Refills 0 .
Immunizations:
Labs:
Follow Up: 4 Weeks
Would the below note be considered 99213? If so, what elements are missing or inadequate to meet the standard for 99214? This provider is a specialist and the system coder puts everything at 99213. We are wondering if it is coding correctly.
Thank you
1. Back pain. 2. Neck pain.
HPI:
Lumbar Spine/Lower Back:
Patient is here today for evalutaion of his back pain. He stated that the pain radiates into his groin and his legs and he has numbness in his legs and feet. Patient also stated that he has pain in his neck that radiates into his arms. He stated that he has numbness in his arms and hands as well. On a scale of 0-10 with 0 being the least amount of pain and 10 being the worst amount of pain, he stated that today his pain level is an 8. He recently had to work on his car and was lying on the concrete. he had a hard time getting back up and ever since then, he has been having more neck pain and arm pain. that was 1 week ago.
Medications: OxyContin 40 mg 1 tab(s) bid, Norco 325 mg-10 mg 1 tab(s) q 4 H, Neurontin 400 mg 1 cap(s) qhs
Allergies: Morphine.
Objective:
Vitals: BP sitting 146/93, Pulse sitting 64, RR 18, Temp 97.7, Ht 71, Wt 305, BMI 42.53.
Examination:
Lumbar Spine/Lower back:
Reflexes: Normal. Sensation: Within normal limits. Provocative Tests: .. Neurologically Stable: No upper motor neuron signs are seen. Location: Lower back. ROM: Within normal limits, Some discomfort is present at extremes of the range of motion.
Cervical Spine/Neck:
ROM: of neck and both upper extremities appear to be within normal limits., Some discomfort is present at extremes of the range of motion.. Location Neck. Reflexes: normal. Sensations: Within normal limits. Provocative Tests: are not performed today. Neurologically Stable: No upper motor neuron signs are seen.
Items reviewed:
Radiology Films not reviewed. Radiology Films not reviewed. Medical records reviewed. Medical records reviewed. Narcotic drug policy is in chart was reviewed with patient today . Narcotic drug policy is in chart was reviewed with patient today . Home exercise program was reviewed and discussed with the patient. Home exercise program was reviewed and discussed with the patient. Current work restrictions are not applicable as patient is not working. Current work restrictions are not applicable as patient is not working.
Assessment:
Assessment:
1. LUMBAR DISC DEGENERATION - 722.52 (Primary)
2. CERVICAL DISC DEGENERATION - 722.4
3. Chronic pain syndrome - 338.4
4. PAIN (SHOULDER) - 719.41
5. POST LAMINECTOMY SYNDROME - 722.83
6. Radicular syndrome of lower limbs - 724.4
7. DISC DIS NEC/NOS-LUMBAR - 722.93
8. Low back pain - 724.2
9. Cervical arthritis - 721.0
10. Radicular syndrome of upper limbs - 723.4
11. LUMBAR STENOSIS - 724.02
Plan:
1. Cervical arthritis
I advised patient to give it another couple weeks for the neck to recover from the stress of him laying on the concrete to fix his car. If at that time he is still not improving, I will get an MRI. Medications are refilled today. NDP is renewed.
2. Others Refill OxyContin tablet, extended release, 40 mg, orally, 60, 1 tab(s), bid, 30 day(s), Refills 0 ; Refill Norco tablet, 325 mg-10 mg, orally, 120, 1 tab(s), q 4 H, 30 day(s), Refills 0 .
Immunizations:
Labs:
Follow Up: 4 Weeks