jmartin106
Contributor
We have a new coder and my docs don't agree with how she is coding. She states that for anything to be counted in MDM it has to be noted in HPI. It does not matter that it is in the assessment and plan or that it was mentioned in ROS. For example. She states that this is coded as only 1 chronic condition and 1 acute - Insomnia and thrush. I feel dumb but I am seeing 3 chronic and 1 acute all addressed with 4 labs ordered. Please correct me if I am wrong. My doc is coding as 99214.
HPI: Patient complains of thrush.
Review of Systems
Constitutional: Negative. Negative for fatigue, fever and general weakness.
Endocrine: Negative.
Hematological/Lymphatic: Negative.
Psychiatric/Behavioral: Negative. Positive for sleeping problems.
HENT: Negative.
Eyes: Negative. Negative for blurred vision and vision loss.
Neurological: Negative. Negative for dizziness.
Respiratory: Positive for cough (chronic). Negative for shortness of breath.
Cardiovascular: Negative for chest pain, dyspnea on exertion and palpitations.
Skin: Negative. Negative for rash.
Musculoskeletal: Positive for arthralgias.
Gastrointestinal: Negative. Positive for acid reflux (improved w/dietary changes). Negative for constipation, diarrhea, nausea and vomiting.
Genitourinary: Negative.
Then exam is pretty lengthy.
A&P:
1. Familial hypercholesterolemia
Assessment & Plan:
Continue Crestor as directed. Zetia added at last office visit. Lab pending. Will update plan of care depending on results.
Discussed healthy lifestyle.
Orders:
2. Hypertension
Assessment & Plan:
Blood pressure is under good control today. Continue current treatment regimen and healthy lifestyle.
Precautions given. Instruction given to contact the clinic with persistent home readings of >140/90.
3. Insomnia
Assessment & Plan:
Continue 10 mg Ambien nightly as needed. May take an extra 5 mg dose, if needed. Follow up every 6 months.
4. Thrush
- nystatin (MYCOSTATIN) 100,000 unit/mL suspension; Take 5 mLs (500,000 Units total) by mouth 4 (four) times daily.
5. Encounter for hepatitis C screening test for low risk patient
- Hepatitis C Antibody, Qualitative Screen
HPI: Patient complains of thrush.
Review of Systems
Constitutional: Negative. Negative for fatigue, fever and general weakness.
Endocrine: Negative.
Hematological/Lymphatic: Negative.
Psychiatric/Behavioral: Negative. Positive for sleeping problems.
HENT: Negative.
Eyes: Negative. Negative for blurred vision and vision loss.
Neurological: Negative. Negative for dizziness.
Respiratory: Positive for cough (chronic). Negative for shortness of breath.
Cardiovascular: Negative for chest pain, dyspnea on exertion and palpitations.
Skin: Negative. Negative for rash.
Musculoskeletal: Positive for arthralgias.
Gastrointestinal: Negative. Positive for acid reflux (improved w/dietary changes). Negative for constipation, diarrhea, nausea and vomiting.
Genitourinary: Negative.
Then exam is pretty lengthy.
A&P:
1. Familial hypercholesterolemia
Assessment & Plan:
Continue Crestor as directed. Zetia added at last office visit. Lab pending. Will update plan of care depending on results.
Discussed healthy lifestyle.
Orders:
- CBC with Differential
- Comprehensive Metabolic Panel
- Lipid Panel
2. Hypertension
Assessment & Plan:
Blood pressure is under good control today. Continue current treatment regimen and healthy lifestyle.
Precautions given. Instruction given to contact the clinic with persistent home readings of >140/90.
3. Insomnia
Assessment & Plan:
Continue 10 mg Ambien nightly as needed. May take an extra 5 mg dose, if needed. Follow up every 6 months.
4. Thrush
- nystatin (MYCOSTATIN) 100,000 unit/mL suspension; Take 5 mLs (500,000 Units total) by mouth 4 (four) times daily.
5. Encounter for hepatitis C screening test for low risk patient
- Hepatitis C Antibody, Qualitative Screen