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msingh23

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Need your input for this Exam portion documentation for a new patient, orthopaedics, Dr. coding as level 4 - 99204 I felt this exam do not meet comprehensive. Please assit is so how?

CC: fractured left humerus and pain

Vital Signs
Height: 68 inches
Weight: 165 pounds
Pulse: 65
Respirations: 12


Left Upper Extremity
Range of motion: decreased with pain at the end of the range
Musc strength/tone: pain related weakness


Neurologic
Coordination: normal coordination
Reflexes: 2+, symmetric, no pathological reflexes
Sensation: No gross sensory deficits noted

Mental Status Exam
Orientation: oriented to time, place, and person
Mood and affect: no alteration in mood or affect

Lt. Shoulder
Comments: There is local lateral L GH discomfort. ROM limited, tight and pain related

Impression CLOSED FRACTURE OF GREATER TUBEROSITY OF HUMERUS (ICD-812.03)
SHOULDER PAIN, LEFT (ICD-719.41)

Thank you.
 
It seems as though most of the exam was focussed on the Left Upper Extremity which could make it level 4. But it does seem to fit a level 3 much easier as it seems more like a low complexity MDM than Moderate MDM to me.

I'd need to see the whole report to verify my conclusions.
 
Are you using the 1997 or 1995 guidelines? Based on 1997, I don't see where you have anywhere near a 99204. That level would require a comprehensive history (4 HPI elements, 2 PFSH elements, and 10 organ systems); a comprehensive exam (every item single item on the CMS checklist), and a moderate MDM. The note you attached does not come anywhere near to documenting that level.

missy874: Where are you getting a detailed exam? That would require 12 bullet points (from CMS's specific list), and I do not see that many. (Using a 1997 musculoskeletal exam, I only see vitals, appearance, coordination, reflexes, sensation, orientation, and mood - that's only 7. For a 1997 general exam, I see vitals, appearance, sensation, orientation, mood, inspection of extremity, range of motion, and muscle strength/tone, which is 8.)

BenCrocker: I am confused. Why would focusing an exam on a single extremity make it a level 4?
 
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