Wiki 99214 - Palpation demonstrates

[MARY K]

I have a DR who insists this is level 4 visit, My biggest issue with this provider is the way his dictation is set-up.My Dr's example reads as follows:

HPI: The patiient is seen today for complaints of left knee pain and popping. The patient states that it has been popping for four months now. She also has swelling and it sometimes will give out. The patient states that she has fallen multiple times onto that knee over the last six months to a year.

PASTMEDICALHISTORY/PAST SURGICAL HISTORY/MEDICATIONS/ALLERGIES/SOCIAL HISTORY/FAMILY HISTORY/REVIEW OF SYSTEMS: Are reviewed on the intake sheet.

EXAMINATION: Well developed,well nourished female,awake,alert and oriented x3. Vital signs are recorded in the chart and are reviewed. Examination today demonstrates the left lower extremity has moderate swelling about the knee compared to the right. This was also noted on x-ray. Valgus and varus stress tests are negative at 0 and 30 degrees. AP drawer is negative. the calf is nontender on pappation. Distal pulsed 2+ and she is neurologically intact.
The patient does have a history of Cerebral Palsy which has caused an Achilles tension and shortening. This is something she has had surgery on in the past, and is also causing some contractile issues today. She does have some weakness of the anterior tibials sue to this as well. Palpation demonstrates there is some mild patellofemoral crepitus and the kneecap is certainly smaller on palpation versus the right leg.
Examination of the lower extremities demonstrates the left leg is short by 1cm on measurement from the ASIS to the medial malleoli. Watching the patient walk today demonstrates that she does have an issue to foot drop causing her to hyperflex the knee,and then snap it forward to allow her to walk causing continued hyperextension to the left knee. She also has bilateral hyperpronation when she stands causing internal rotation of her knees.
IMAGING:X-rays were done today that showed joint space preserved between the femur and tibia. There are no arthritic changes noted. The patient does have a malformed patella of the left knee versus right with a deeper patellofemoral groove.
Diagnosis:Chronic sprain/strain of the left knee secondary to malformation of the patella as well as motor function changes due to cerebral palsy. Achilles tendon shortness with tightness only allowing a forced 90 degree flexion of the ankle and weakness of the anterior tibial muscles.
PLAN: The patient will have orthotics ordered for her lower extremities. She will also use a 5mm lift in the left side. She will also be sent for physical therapy for the left lower extremity to include the left knee as well as the achilles. They should do modalities as well as stretching exercises. She should not be placed on a treadmill. The patient will followup in approximately four to five weeks for re-evaluation.

Please if anyone can help me sort my E/M mess I would appreciate it. The Physician circled a level 4 extablished patient on encounter, but the patient is new. I only find enough information on this dictation for a level 2 new pt visit.

Thanks to anyone that can help me

 

[swilliams2]

Based on what I see here, you are right. Since it is a new patient it it probably a 99202 based on how much HX and ROS was documented on the intake sheet. I can't count the bullets because they are not included. If it was an established patient, it could be a 99214, again depending on the HX and ROS. Being new makes a big difference.

 

[MnTwins29]

Both are "right"

I found the documentaion to be 99202 for a new patient and 99214 for an established patient. Providers, from my experience, need frequent reminders of the different requirements for new vs. established patients. It sounds to me like this physician thought that a "level 4" would be the same for new AND established patients.

 

[Naveen Rachagolla]

I found the documentaion to be 99202 for a new patient and 99214 for an established patient. Providers, from my experience, need frequent reminders of the different requirements for new vs. established patients. It sounds to me like this physician thought that a "level 4" would be the same for new AND established patients.

Hi Twins,

I have a question which always puts me in ?

If the Medical record or if the DOC states that ROS is reviewed and no changes or unchanged or else from the above example its says Are reviewed on the intake sheet if it states like that How r we going to take it or consider that ?

 

[MARY K]

99214

First off I would like to thank everyone for responding.
Back to my posted dictation: Another concern was No Chief Complaint listed, I was under the impression this was needed on all E/M whether pt was new or established.
Is referring to the Intake Sheet for ROS in dictation enough or does this Intake Sheet need to be initialed and dated?

 

[swilliams2]

Your chief complaint is listed as: "complaints of left knee pain". yes, the intake sheet needs to be dated and initaled.