Wiki External MRI/CT scans reviewed by same provider twice in 1 and a half years.

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wynonna

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External MRI/CT scans of brain reviewed by same provider twice in 1 and a half years.
She reported normal findings in May of 2020.
In yesterday's visit, she looked at them again to re-evaluate persistent vertigo.
Patient has new neck pain which she orders an ultrasound for.
Would this count as 2 tests evaluated and 1 ultrasound ordered? or just 1 ultrasound ordered?
 
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You cannot count reviewing the same test more than once by the same provider (or same specialty provider in the same group).
 
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On a side note, whether it's one or two tests wouldn't even factor into outpatient E/M leveling.
Problems: At least level 3, maybe 4. Neck pain is either going to be acute, uncomplicated - level 3 or acute, complicated - level 4. If the chronic vertigo is stable - level 3 or if not responding to treatment plan - level 4.
Data is level 2 for 1 ultrasound.
Risk is at least level 3 for the ultrasound. If rx ordered (or other moderate risk), level 4.
Just on problems and risk, you are either level 3 or level 4. So even if the data were level 3 (but it's really level 2), it doesn't change your coding.
 
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That was my finding too. For moderate under Problems, my chart says "1 acute complicated injury" but doesn't that include complicated illness too? What are examples of complicated illnesses for ENT? How do we differentiate between complicated and uncomplicated? The example I remember for acute complicated injury is "brief loss of consciousness with head injury"
thank you so much Christine
 
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For moderate, illness would be acute illness with systemic symptoms, not complicated illness. For low or high problems, illness or injury are lumped together. For moderate, they are described and listed separately.


Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness.
 
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