Wiki E/M - Pt denies any change in symptoms

[svms]

I am coding an orthopedic office visit.

I was taught that each document should stand alone. I should not have to refer to a previous office note when coding.

I am looking at the medical decision making risk table. The moderate level for 1 or more chronic illnesses with mild exacerbation, progression...

The patient was last seen July 2013. Patient was again seen Feb 2014. Both of these visits discuss the progression of the illness.

The March note subjective states,
"Subjective Findings: Patient is a 43 year old female who presents for follow up after neurology consult. Patient denies any change in symptoms. Patient states neurologist states nothing neurological, he feels all of her symptoms are coming from her lumbar spine."

My doctor gives me a good exam (8 Organ Systems).

My question is this... With a good exam, as well as considering the following diagnosis's in my assessment, does it warrant a level 4. I want to give it a level 4, but can it hold up to an audit.



Patient has :
722.93 Lumbosacral disc disease (primary encounter diagnosis)
Note: L4-5 and L5-S1
Plan: EMG, 2 EXTREMITIES

722.52 DDD (degenerative disc disease), lumbosacral
Note: L4-5 and L5-S1
Plan: EMG, 2 EXTREMITIES

721.42 Lumbar spondylosis with myelopathy
Note: L4-5 and L5-S1
Plan: EMG, 2 EXTREMITIES

722.93 Disc disorder of lumbar region
Note: L4-5 and L5-S1
Plan: EMG, 2 EXTREMITIES

782.0 Numbness and tingling of both legs
Note: B/L LE
Plan: EMG, 2 EXTREMITIES

 

[MnTwins29]

Since the patient's version would fall under HPI and the history element, that would be the one to drop with an established patient. However, looking at the MDM causes concern for me on 99214 because the same test is going to be performed for all the conditions listed. That gives one data point. Without any other documentation, the best that can be done for level of risk, IMO, is low. And even if each of those conditions is listed individually, you have 4+ for # of dx, 1 data point and low risk, resulting in low MDM. Assuming you have SF/L History, you have a comprehensive Exam and low MDM - I get 99213.

Would love to see what others think.

 

[dtlandry67]

My question would be where does the documentation demonstrate that the illnesses are exacerbated or have progressed/worsened? The HPI isn't showing it and the Assessment has no status listed for each dx. When training a physician I always recommend a status with each treated condition. For example, low back pain, worsening. If there is no status it is looked at as stable or improving.

I can't give you a level without seeing the exam documentation but with just this I agree with Lance. A level 4 may be difficult to defend.