Wiki Level 5 EP visit based on time

[ollielooya]

Really cautious on dr's scoring of a level 5 based on time so here's the scrubbed note. Insurance = commercial carrier. Just need some add'l thoughts RE the high assignment from list colleagues!

GENL: NAD A&Ox3. Well groomed and dressed. Affect/mood = a bit anxious at times
VS: above

HEENT: NCAT. PERRL. EOMI
B/L TM/pharynx/nares clear
Neck; Supple
Lungs: CTA
CV: Heart RRR w/o M/R/G/H/T
Derm: fine papular rash on dorsum of both hands' visible worse w/pt. scratching. Open and closed comedones face, pustules lower face

I/P
1) RASH-NONSPEC: 782.1
dermatitis
unclear etiology; possible due to some gloves rec'd for xmas
Avoid dyes, fragrances; d/c gloves
TCN cream bid prn
F/up no resolution

2) HEADACHE: 784.0
Will emperically tx w/biaxin for presumed sinusitis
If sx do not resolve discussed CT to r/out other potential pathology

3) ACNE NEC: 706.1
increase cleasing to bid
clinda topical bid
differin qhs

add vivite scrub
hyalogy prn dryness

no picking
only non-comedogenic makeup

Pt also wanted advice for weight loss. Discussed ultimate goal to ________.
Discussed rational t. loss methods. She has already begun using an app to track
calores.
exercise- the suboxone taper causes her body aches so caution not to overdo it.

flu shot given today.

60 min spent with greater than 50% time counseling and coordinating patient care.

99215

 

[MikeEnos]

As an auditor, I'd agree with that coded as a level 5. The 3 important things to document are:
1) The total length of the visit
2) Greater than 50% was spent face to face with the patient counseling and/or coordinating care and
3) The content

In this case, the assessment and plan mentions the topics discussed regarding weight loss, exercise, using an iphone app to track calories, etc. If there is concern, I'd urge a little more detail about the discussion instead of just topics, but this seems fine to me. I certainly couldn't put myself in the shoes of an insurance auditor and think of a valid way to disagree with it.

 

[ollielooya]

Thank you, Mike. Your input is greatly appreciated. BTW, nice website and there's some excellent information in there!