Wiki Help coding E&M for Ortho when exam not complete

[tatumroe]

Before I said anything to my provider I wanted to be sure and have a complete and accurate answer for him. He is a specialist in orthopedics and is only addressing the area of concern in his Exam portion of his progress note. Due to this, I am concerned about having to code for a much lower level of E&M for him than I believe he intends to report for. I wanted to suggest to him that he include time in all of his notes going forward so we could do time-based coding for him. Could someone let me know if that is correct based on the documentation I am seeing here (see below)? Or when it comes to specialty is a limited exam expected, I cannot find anything that would separate them out, it appears without a more detailed exam documented I will be forced to report a lower E&M level.

Subjective: Chief Complaints: 1. Avulsion on left hand. HPI: Left ring finger: Denies : The pain. She reports injury to the end of her left ring finger on approximately 8 days ago. She noted an extension lag of the DIP joint with some redness and swelling of this area. She has been splinting the DIP joint in extension appropriately. She denies any numbness or tingling. ROS: All Other Systems: Review of Systems (ROS) All others negative except those mentioned in HPI. Medical History: Gastro-esophageal reflux disease without esophagitis, Chronic atrial fibrillation, Hx of colonic polyps, Borderline hyperlipidemia, Chronic kidney disease, stage II (mild), Hypertensive CKD Stage 1-4 or uns stage, Osteoarthritis of left knee, Mild tricuspid insufficiency, Diastolic congestive heart failure, Mild pulmonary hypertension, Atrial Fibrillation/Secondary hypercoaguable state w/CHADSVASC score >= 2, Hypertensive heart and CKD with heart failure and CKD Stage 1-4 or Unsp stage, Centrilobular emphysema, Aortic atherosclerosis, Pulmonary HTN, Chronic atrial fibrillation. Surgical History: Right Knee Arthroscopy 6/3/15, Bilateral Carpal Tunnel Release 1994, Cadiac Ablation 10/30/15, Perineal Abscess 12/2016, MVR/TVR 10/2020, Bilateral Cataract Surgery 2018. Hospitalization/Major Diagnostic Procedure: FHW - Chest Pain 2/1/17, AdventHealth Waterman - MVR/TVR 10/2020. Family History: Father: deceased 73 yrs, congestive heart failure. Mother: deceased 92 yrs, heart failure. 2 brother(s) , 2 sister(s) . . brother alive, 77, mother- heart problems.- Deceased Father CHF - Deceased. Social History: Tobacco Use: Tobacco Use/Smoking Are you a former smoker, Additional Findings: Tobacco Non-User Ex-cigarette smoker. Drugs/Alcohol: Alcohol Screen (Audit-C) Did you have a drink containing alcohol in the past year? Yes, How often did you have a drink containing alcohol in the past year? Monthly or less (1 point), How many drinks did you have on a typical day when you were drinking in the past year? 1 or 2 drinks (0 point), How often did you have 6 or more drinks on one occasion in the past year? Never (0 point), Points 1, Interpretation Negative. Medications: Taking Tylenol 325 MG Tablet 1 tablet as needed Orally every 4 hrs, Notes: 500 MG, Taking Coenzyme Q10 300 MG Capsule 1 capsule with a meal Orally Once a day, Taking Vitamin B12 1000 Tablet 1 tablet Orally Once a day, Taking Folic Acid 1 MG Tablet 1 tablet Orally Once a day, Taking Vitamin B6 100 MG Tablet 1 tablet Orally Once a day, Taking PreserVision AREDS - Capsule 1 Capsule Orally Once a day, Taking Fish Oil 1200 MG Capsule 1 capsule Orally Once a day, Taking Metoprolol Tartrate 50 MG Tablet 1 tablet with food Orally Twice a day, Taking Warfarin Sodium 2.5 MG Tablet 1 tablet Orally Once a day, Not-Taking Warfarin Sodium 3 MG Tablet 1 tablet Orally Once a day, Not-Taking Trelegy Ellipta 100-62.5-25 MCG/INH Aerosol Powder Breath Activated 1 puff Inhalation Once a day, Not-Taking Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution 1 puff as needed Inhalation every 4 hrs, Medication List reviewed and reconciled with the patient Allergies: Cortisone: swelling all over - Allergy. Objective: Vitals: Temp 97.8 F, HR 56 /min, BP 144/81 mm Hg, Ht 69 in, Wt 192.4 lbs, BMI 28.41 Index, RR 16 /min, Oxygen sat % 96 %. Examination: Left ring finger: INSPECTION: Minimal swelling over the dorsum of the DIP joint with very mild overlying erythema. PALPATION: Mild tenderness at the base of the distal phalanx dorsally. VASCULAR: good capillary refll < 3 seconds. SENSATION: light touch intact. There is in terminal extension lag of the left ring finger consistent with a mallet finger. Assessment: Assessment: 1. Mallet finger of left hand - M20.012 (Primary) Plan: 1. Mallet finger of left hand Imaging: HAND LT 3V Notes: Patient presents with a bony mallet of the left ring finger. The avulsion is approximately 5-10% of the joint surface with no instability of the joint noted. Recommend 6-8 weeks of extension splinting time and she was instructed to obtain a mallet finger splint. Follow-up in 4 weeks with new x-ray. 2. Others Notes: I personally reviewed the left hand x-rays from Akumin which demonstrate an avulsion fracture of the distal phalanx dorsally of the left ring finger. This is approximately 5-10% of the joint with no joint instability appreciated. Follow Up: 4 Weeks

 

[jkyles]

Hi there, this appears to be an office/other outpatient visit. As such, the history and physical exam don't count toward the level. I do think it makes sense to capture time, but to get full credit the doctor will need to document all time spent on the patient's care on the date of the visit. For example, if the doctor reviewed the film before the encounter he'd need to document how much time he spent doing that.

 

[amyjph]

Agree with the answer above. If you are talking about an office/outpatient visit after 1/1/21 the E&M is based on either time or MDM. If you are talking about an ED, IP, consult, or obsv it would be the other E&M guidelines.
That said, orthopedic surgeons rarely have comprehensive, multi-system exams in the office setting. In the pre-21 E&M world the 1995 exam would normally be the way to go because they generally wouldn't meet the bullets for 1997. I have seen that if they are a physiatrist or possibly a spine surgeon the exams may be more extensive. Of course, there are always exceptions to this especially in the elderly or someone with many co-morbid conditions complicating care. Sometimes if the patient was a multi-trauma and they are following up in office they may have it but then it would usually be a post op.

In my opinion the example you give above is: # problems: Low (1 acute, uncomplicated), MDM elements: Limited (reviewed XR which appears to be external & not ordered by this MD), Risk: Low (splint & 4 week f/u, no Rx, no surgery, no procedure, etc.) = Level 3 (99203, 99213). Even if the provider documented time it would be hard for me to believe a hand surgeon took 30-39 total minutes for this type of visit so you would be back to a level 3 anyway.

Also, in looking at this he calls it mallet finger but this is a new injury and actually stated as: "avulsion fracture of the distal phalanx dorsally of the left ring finger" which would lead me more towards the "S" ICD-10s rather than the "M". I didn't look in the book index to confirm. The HPI says: "injury to the end of her left ring finger on approximately 8 days ago".

In non-office/outpatient pre-21 it's a new 2 or an established 3. (C/EPF/Low)

This actually isn't that bad of a note when it comes to ortho notes. I once had a seasoned hand surgeon tell another newer hand surgeon during an E&M training to think of E&M like this: "What's wrong, how bad is it, what are we doing about it, and how soon did we tell the patient to come back for follow up?" I still use this to help me think about E&M levels all the time.