Wiki Em coders

[Naveen Rachagolla]

Can someone audit this note for me...with 95 DGs

DATE OF VISIT: 03/28/XX

DX: Carcinoma of the colon, status post resection with 6 positive lymph nodes.

RX: Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months.

HX: The patient returns for follow-up. He received approximately 6 months of adjuvant treatment with Capecitabine 2 weeks on and 1 week off. His liver function tests became abnormal. (Location and Quality)This raised the question of recurrence of his cancer. However, on review, his alkophoserous was persistently elevated(Severity) from the beginning being 203 on 11/30/XX, 238 on 12/20/XX and 202 on 02/01/Xx and 02/19/Xx. This was not necessarily implied liver disease. He had an AST of 47 on 11/30/XX which rose to 194 on 12/20/XX, 104 on 02/01/XX and 44 WNL on 02/29/XX. ALT was 121 on 11/30/xx, 289 on 12/20/XX and 150 on 02/01/XX and 63 on 02/29/XX. (Timing)In the meantime his CEA has been normal at 2.1 on 11/30/XX and 1.5 on 02/29/XX. The rise and fall of liver function test is more consistent with acquired viral hepatitis, probably from his surgery although it could represent early metastatic disease, it is not entirely compatible with that. The normal CEA is definitely against that. To evaluate this further, a CT scan of the abdomen will be done next week. Otherwise the patient is doing well without weight loss, anorexia, bowel symptoms or breathing problems. The remainder of the ROS is unremarkable.

History is Detail ( HPI- Extended, ROS is Extended and Pertinent PFSH(Medical Hx)

PE: Constitutionals: Alert, middle-aged white male in no acute distress. WT: 161. TEMP: 98.3. P: 73. R: 18. BP: 138/69. Skin: Unremarkable. No icterus. Lymph nodes: No significant peripheral adenopathy. HEENT: Clear sclerae. Normal ENT exam. No mucositis. Neck: Supple. No JVD or thyroid abnormality. Lungs: Clear to P&A. Heart: Regular. No murmurs, gallops or rubs. Abdomen: Soft. Nontender. No organomegaly, mass or ascites. Extremities: No edema or focal bony tenderness. Neurologic: Alert and oriented without focal deficits.

Exam is Comprehensive ( Eight Organ Systems were Examined)

LAB STUDIES: As above.

A&P: Carcinoma of the colon, status post resection with positive lymph nodes. The patient received a 6 month course of adjuvant chemotherapy with Capecitabine. The patient had an elevation of liver function tests starting in late November and rising in December and February but subsiding by the end of February. By the end of February, the last values tested, transaminases were normal. His alk phos has been elevated throughout. His CEA has been normal throughout. This is most consistent with viral hepatitis, probably acquired at the time of his surgery from transfusions rather than recurrence of his colon cancer. He has a normal CEA. His liver function tests have returned to normal without intervention. Even if this was colon cancer which was responding favorably to Capecitabine, the elevation in transaminases between November 30th and December 20th would have suggested a resistance to Capecitabine which should not have resolved on Capecitabine. Therefore, the liver function tests are not likely compatible with metastatic disease. In addition, the CEA is not elevated. Therefore, I will conclude that there is a low probably of this being a metastatic disease and mostly this is viral hepatitis. However, to evaluate this further, CT scan of the abdomen will be obtained. The patient will have a CMP and CEA drawn today and will return to see me 23 days following the CT scan with results.

MDM is Moderate(New problem to the Examiner with no additional plan 3 points, Labs from Medicine sections 1 point and Risk is Moderate(undiagnosed new problem with uncertain prognosis)

I came up with level 99214

 

[Pam Warren]

Hi, here's my opinion. I don't use lab results as quality and severity, since it's not subjective data. So here's what I came up with.

DATE OF VISIT: 03/28/XX

DX: Carcinoma of the colon, status post resection with 6 positive lymph nodes.

RX: Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months. (Modifying Factors)
HX: The patient returns for follow-up. He received approximately 6 months of adjuvant treatment with Capecitabine 2 weeks on and 1 week off. (Duration) His liver function tests became abnormal. (Associated signs) This raised the question of recurrence of his cancer. (context) However, on review, his alkophoserous was persistently elevated from the beginning being 203 on 11/30/XX, 238 on 12/20/XX and 202 on 02/01/Xx and 02/19/Xx. This was not necessarily implied liver disease. He had an AST of 47 on 11/30/XX which rose to 194 on 12/20/XX, 104 on 02/01/XX and 44 WNL on 02/29/XX. ALT was 121 on 11/30/xx, 289 on 12/20/XX and 150 on 02/01/XX and 63 on 02/29/XX. In the meantime his CEA has been normal at 2.1 on 11/30/XX and 1.5 on 02/29/XX. This is data review, not history. The rise and fall of liver function test is more consistent with acquired viral hepatitis, probably from his surgeryalthough it could represent early metastatic disease, it is not entirely compatible with that. The normal CEA is definitely against that. To evaluate this further, a CT scan of the abdomen will be done next week. This is not history documentation, it's assessment data. Otherwise the patient is doing well without weight loss, anorexia, bowel symptoms or breathing problems. The remainder of the ROS is unremarkable. (Constitutional, GI, Pulmonary.) If you can, discourage your provider from using "unremarkable".

Brief HPI. There's no PFSH to allow for an extended. No reveiew of medication/allergy/surgical history list. No family history, no social history. His narrative is his review of the current lab results and his thought process....not subjective data. I was pretty generous with the four HPI elements....


PE: Constitutionals: Alert, middle-aged white male in no acute distress. WT: 161. TEMP: 98.3. P: 73. R: 18. BP: 138/69. Skin: Unremarkable. (I don't count "unremarkable". Per 1995 guidelines, only "Negative" or "Normal" is appropriate) No icterus. Would give credit for this. Lymph nodes: No significant peripheral adenopathy. HEENT: Clear sclerae. Normal ENT exam. No mucositis. Neck: Supple. No JVD or thyroid abnormality. Lungs: Clear to P&A. Heart: Regular. No murmurs, gallops or rubs. Abdomen: Soft. Nontender. No organomegaly, mass or ascites. Extremities: No edema or focal bony tenderness. Neurologic: Alert and oriented without focal deficits.

Exam is Detail (Extended Exam on 2-7 Organ Systems/Body Areas) I disagree. Which BA/OS was extendedly documented? It's not enough to just mention the OS/BA per 1995 guidelines:

Detailed [FONT=Arial,Arial][FONT=Arial,Arial]-- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). [/FONT][/FONT]

One (preferably the OS relative to the chief complaint), must be documented in detail. The chief complaint (or diagnosis above) is colon cancer, but the real problem is the elevated labs. I wouldn't call the abdominal exam "detailed". Should have also documented bowel sounds, percussion, CVA tenderness, guarding, reflexes. Is there a surgical site? Colostomy site? Why was that not examined? He only examined peripheral lymph nodes? In a cancer patient with a possible recurrence? I'm sure he did the work, but it wasn't documented.

LAB STUDIES: As above.

A&P: Carcinoma of the colon, status post resection with positive lymph nodes. The patient received a 6 month course of adjuvant chemotherapy with Capecitabine. The patient had an elevation of liver function tests starting in late November (looky here....Timing HPI!!) and rising in December and February but subsiding by the end of February. By the end of February, the last values tested, transaminases were normal. His alk phos has been elevated throughout. His CEA has been normal throughout. This is most consistent with viral hepatitis, probably acquired at the time of his surgery from transfusions rather than recurrence of his colon cancer. He has a normal CEA. His liver function tests have returned to normal without intervention. Even if this was colon cancer which was responding favorably to Capecitabine, the elevation in transaminases between November 30th and December 20th would have suggested a resistance to Capecitabine which should not have resolved on Capecitabine. Therefore, the liver function tests are not likely compatible with metastatic disease. In addition, the CEA is not elevated. Therefore, I will conclude that there is a low probably of this being a metastatic disease and mostly this is viral hepatitis. However, to evaluate this further, CT scan of the abdomen will be obtained. The patient will have a CMP and CEA drawn today and will return to see me 23 days following the CT scan with results.

MDM = Low. See HPI: The patient returns for follow-up. I probably wouldn't call this a new problem, but I would give 2 points for an established problem, worsening, because of the abnormal labs. 2 points for data....reviewed labs, ordered CT. Risk is moderate. The nature of the presenting problem....abnormal labs in a colon cancer patient certainly would warrant a higher E&M code, but the documentation isn't there. This is an perfect example of how providers shoot themselves in the foot, but it's a great learning tool, if you can provide your physician with feedback.


Based on the provider's documentation, I would code this as a 99213. His History was lacking PFSH and the HPI contained a lot of objective data and decision making documentation. He also needs to provide a more detailed examination. Educate your provider on the concept of "Problem, Status, Treatment", and that his HPI, ROS, Exam and decision making should all follow the chief complaint throughout the note. The presenting problem is not the cancer (as per diagnosis), but for the abnormal labs.

 

[Naveen Rachagolla]

Hi, here's my opinion. I don't use lab results as quality and severity, since it's not subjective data. So here's what I came up with.

DATE OF VISIT: 03/28/XX

DX: Carcinoma of the colon, status post resection with 6 positive lymph nodes.

RX: Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months. (Modifying Factors)
HX: The patient returns for follow-up. He received approximately 6 months of adjuvant treatment with Capecitabine 2 weeks on and 1 week off. (Duration) His liver function tests became abnormal. (Associated signs) This raised the question of recurrence of his cancer. (context) However, on review, his alkophoserous was persistently elevated from the beginning being 203 on 11/30/XX, 238 on 12/20/XX and 202 on 02/01/Xx and 02/19/Xx. This was not necessarily implied liver disease. He had an AST of 47 on 11/30/XX which rose to 194 on 12/20/XX, 104 on 02/01/XX and 44 WNL on 02/29/XX. ALT was 121 on 11/30/xx, 289 on 12/20/XX and 150 on 02/01/XX and 63 on 02/29/XX. In the meantime his CEA has been normal at 2.1 on 11/30/XX and 1.5 on 02/29/XX. This is data review, not history. The rise and fall of liver function test is more consistent with acquired viral hepatitis, probably from his surgeryalthough it could represent early metastatic disease, it is not entirely compatible with that. The normal CEA is definitely against that. To evaluate this further, a CT scan of the abdomen will be done next week. This is not history documentation, it's assessment data. Otherwise the patient is doing well without weight loss, anorexia, bowel symptoms or breathing problems. The remainder of the ROS is unremarkable. (Constitutional, GI, Pulmonary.) If you can, discourage your provider from using "unremarkable".

Brief HPI. There's no PFSH to allow for an extended. No reveiew of medication/allergy/surgical history list. No family history, no social history. His narrative is his review of the current lab results and his thought process....not subjective data. I was pretty generous with the four HPI elements....


PE: Constitutionals: Alert, middle-aged white male in no acute distress. WT: 161. TEMP: 98.3. P: 73. R: 18. BP: 138/69. Skin: Unremarkable. (I don't count "unremarkable". Per 1995 guidelines, only "Negative" or "Normal" is appropriate) No icterus. Would give credit for this. Lymph nodes: No significant peripheral adenopathy. HEENT: Clear sclerae. Normal ENT exam. No mucositis. Neck: Supple. No JVD or thyroid abnormality. Lungs: Clear to P&A. Heart: Regular. No murmurs, gallops or rubs. Abdomen: Soft. Nontender. No organomegaly, mass or ascites. Extremities: No edema or focal bony tenderness. Neurologic: Alert and oriented without focal deficits.

Exam is Detail (Extended Exam on 2-7 Organ Systems/Body Areas) I disagree. Which BA/OS was extendedly documented? It's not enough to just mention the OS/BA per 1995 guidelines:

Detailed [FONT=Arial,Arial][FONT=Arial,Arial]-- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). [/FONT][/FONT]

One (preferably the OS relative to the chief complaint), must be documented in detail. The chief complaint (or diagnosis above) is colon cancer, but the real problem is the elevated labs. I wouldn't call the abdominal exam "detailed". Should have also documented bowel sounds, percussion, CVA tenderness, guarding, reflexes. Is there a surgical site? Colostomy site? Why was that not examined? He only examined peripheral lymph nodes? In a cancer patient with a possible recurrence? I'm sure he did the work, but it wasn't documented.

LAB STUDIES: As above.

A&P: Carcinoma of the colon, status post resection with positive lymph nodes. The patient received a 6 month course of adjuvant chemotherapy with Capecitabine. The patient had an elevation of liver function tests starting in late November (looky here....Timing HPI!!) and rising in December and February but subsiding by the end of February. By the end of February, the last values tested, transaminases were normal. His alk phos has been elevated throughout. His CEA has been normal throughout. This is most consistent with viral hepatitis, probably acquired at the time of his surgery from transfusions rather than recurrence of his colon cancer. He has a normal CEA. His liver function tests have returned to normal without intervention. Even if this was colon cancer which was responding favorably to Capecitabine, the elevation in transaminases between November 30th and December 20th would have suggested a resistance to Capecitabine which should not have resolved on Capecitabine. Therefore, the liver function tests are not likely compatible with metastatic disease. In addition, the CEA is not elevated. Therefore, I will conclude that there is a low probably of this being a metastatic disease and mostly this is viral hepatitis. However, to evaluate this further, CT scan of the abdomen will be obtained. The patient will have a CMP and CEA drawn today and will return to see me 23 days following the CT scan with results.

MDM = Low. See HPI: The patient returns for follow-up. I probably wouldn't call this a new problem, but I would give 2 points for an established problem, worsening, because of the abnormal labs. 2 points for data....reviewed labs, ordered CT. Risk is moderate. The nature of the presenting problem....abnormal labs in a colon cancer patient certainly would warrant a higher E&M code, but the documentation isn't there. This is an perfect example of how providers shoot themselves in the foot, but it's a great learning tool, if you can provide your physician with feedback.


Based on the provider's documentation, I would code this as a 99213. His History was lacking PFSH and the HPI contained a lot of objective data and decision making documentation. He also needs to provide a more detailed examination. Educate your provider on the concept of "Problem, Status, Treatment", and that his HPI, ROS, Exam and decision making should all follow the chief complaint throughout the note. The presenting problem is not the cancer (as per diagnosis), but for the abnormal labs.

Pam...will this statement not referring to Past Medical Hx

RX: Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months

 

[Lynda Wetter]

RX: Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months. (Modifying Factors)

Would you give this Modifying factors, it does not state the outcome?

 

[LLovett]

I agree with 99214

It is not a very pretty note but it supports a 99214 in my opinion.

I'm going to disregard the history on this one all together because it is ugly and I don't need it to support the 99214. I agree with Pam this is a teaching opportunity.

This is a prime example of the subjectivity of 95 exam guidelines. I came up with 10 organ systems, noted below, so I agree it is a comp exam.

PE: Constitutionals: Alert, middle-aged white male in no acute distress. WT: 161. TEMP: 98.3. P: 73. R: 18. BP: 138/69. Cons
Skin: Unremarkable. No icterus. Skin
Lymph nodes: No significant peripheral adenopathy. Lymph
HEENT: Clear sclerae. Eyes
Normal ENT exam. No mucositis. ENT
Neck: Supple. No JVD or thyroid abnormality.
Lungs: Clear to P&A. Resp
Heart: Regular. No murmurs, gallops or rubs. CV
Abdomen: Soft. Nontender. No organomegaly, mass or ascites. GI
Extremities: No edema or focal bony tenderness. MS
Neurologic: Alert and oriented without focal deficits. Psych


LAB STUDIES: As above.

A&P: Carcinoma of the colon, status post resection with positive lymph nodes. The patient received a 6 month course of adjuvant chemotherapy with Capecitabine. The patient had an elevation of liver function tests starting in late November and rising in December and February but subsiding by the end of February. By the end of February, the last values tested, transaminases were normal. His alk phos has been elevated throughout. His CEA has been normal throughout. This is most consistent with viral hepatitis, probably acquired at the time of his surgery from transfusions rather than recurrence of his colon cancer. He has a normal CEA. His liver function tests have returned to normal without intervention. Even if this was colon cancer which was responding favorably to Capecitabine, the elevation in transaminases between November 30th and December 20th would have suggested a resistance to Capecitabine which should not have resolved on Capecitabine. Therefore, the liver function tests are not likely compatible with metastatic disease. In addition, the CEA is not elevated. Therefore, I will conclude that there is a low probably of this being a metastatic disease and mostly this is viral hepatitis. However, to evaluate this further, CT scan of the abdomen will be obtained. The patient will have a CMP and CEA drawn today and will return to see me 23 days following the CT scan with results.

This is the interesting part, for Dx points we have at least 1 established problem that is worsening, Colon CA 2 points, the possible hepatitis is either established or new with work-up. Regardless of that we have at minimum 3dx points, 2 for the cancer and at least 1 for the possible hepatitis. We have 2 data points and at minimum moderate risk. Giving us Moderate MDM.

This is my take on it,

Laura, CPC, CPMA, CEMC

 

[Naveen Rachagolla]

Thank you all for you ideas and contribution, i think there is a lot in these posts to learn how to judge a record or the physician work.

Once again thank you all.

 

[Pam Warren]

PE: Constitutionals: Alert, middle-aged white male in no acute distress. WT: 161. TEMP: 98.3. P: 73. R: 18. BP: 138/69. Cons
Skin: Unremarkable. No icterus. Skin
Lymph nodes: No significant peripheral adenopathy. Lymph
HEENT: Clear sclerae. Eyes
Normal ENT exam. No mucositis. ENT
Neck: Supple. No JVD or thyroid abnormality.
Lungs: Clear to P&A. Resp
Heart: Regular. No murmurs, gallops or rubs. CV
Abdomen: Soft. Nontender. No organomegaly, mass or ascites. GI
Extremities: No edema or focal bony tenderness. MS
Neurologic: Alert and oriented without focal deficits. Psych

Here's where auditors disagree...we don't give credit for Psych unless they state A/O X3. So then we're left with detailed. But none of these OS (in my opinion) are documented in detail (particularly the ones related to the CC, which is what you want to see).


Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months
I considered this a modifying factor, because it indicates what had been done for the condition. I'm not sure that it's necessary to state whether the treatment was successful or not. Good point, though.

In my mind, PFSH (past history) includes a listing of current medications and dosages, past surgeries, current and past diseases, allergies and any other personal medical information. I prefer to see this documented separately, to show that there was a specific, acknowledged review of PFSH. (my preference).

We're pretty stringent with our providers, and have even developed some of our own coding guidelines where our contractor (NHIC) is murky in the details. Our hope is to be audit-proof, and to support the detail necessary for ICD-10, as well as to show clear medical necessity.

It's always interesting to see others' opinions.....good discussion!

 

[Lynda Wetter]

Patient received adjuvant chemotherapy with Capecitabine 2 weeks on and 1 week off for approximately 6 months
I considered this a modifying factor, because it indicates what had been done for the condition. I'm not sure that it's necessary to state whether the treatment was successful or not. Good point, though



The definition of Modifying Factors that I was refering to is coming from the CEMC study guide 2012 page 17.
*Its a statement in the patients own words on what is "Modifying" the problem.
I'm not too sure the statement is in the patients own words.

 

[LLovett]

The official guidelines don't actually state that anything other than the cc is "usually stated in the patients own words" and since history can be gathered from someone other than the patient it stands to reason that none of it has to be in the patients own words. The other thing to consider is when you are stating that you are not sure something is in the patients words, you are making a judgement call that is out of the scope of an auditor/coder.

The official guidelines don't really define the elements very clearly, many carriers do provide their own definitions though. WPS Medicare seems to indicate they do want the modifying factor and the outcome based on their audit tool. Some carriers may not.

Pam, I agree with A&Ox3 for 97 but based on the carriers I have dealt with it is not required for 95. I have no problem with being conservative though so I understand where you are coming from!

Laura, CPC, CPMA, CEMC