Wiki Level of Visit

[JCampbell]

Can someone help me with the following provider note. It is being questioned if this would stand up in an audit. I believe that it would but I would like another opinion.

Past Medical Hx
HEENT: Alergic Rhinitis
Cardio: HTN, Pacemaker,SVT
Psychiatric: Depression

Past Surgical Hx
Cardio: Pacemaker
Gastro: Appendectomy, Hernia Repair(X2)
Musculoskeletal: L4 Surgery

Tobacco status: Current every day smoker

CC: Backache/med refills
"Patient is a 45 year old male who presents with chronic back pain after multiple surgeries. He just had kidney stones removed by Dr. Stokes with urology. He is now pain free from that but still has chronic back pain which is seeing pain management for the end of January. He states that he normally takes 2-3 Vicodin 5 325mg. He would like to start weaning off of this amount. Review of systems otherwise negative.

Exam:
CV: Regular rate rhythm S1-S2 no murmurs auscultated
Lungs: Bilaterally clear to ausculation
Extremeties:Negative for edema

Assessment/Plan
724.5 Backache Unspec
Rx Norco 7.5/325mg one by mouth every 4-6 hours #120 no refills
Followup pain management
Other medications refilled
Return to clinic in one month for narcotic followup

Also contained within in the note are medications that have been added, renewed or discontinued.

The dispute it whether the exam was appropriate/extensive enough for this visit.

Any assistance with this is greatly appreciated.

Thanks!

 

[btadlock1]

Can someone help me with the following provider note. It is being questioned if this would stand up in an audit. I believe that it would but I would like another opinion.

Past Medical Hx
HEENT: Alergic Rhinitis
Cardio: HTN, Pacemaker,SVT
Psychiatric: Depression

Past Surgical Hx
Cardio: Pacemaker
Gastro: Appendectomy, Hernia Repair(X2)
Musculoskeletal: L4 Surgery

Tobacco status: Current every day smoker

CC: Backache/med refills
"Patient is a 45 year old male who presents with chronic back pain after multiple surgeries. He just had kidney stones removed by Dr. Stokes with urology. He is now pain free from that but still has chronic back pain which is seeing pain management for the end of January. He states that he normally takes 2-3 Vicodin 5 325mg. He would like to start weaning off of this amount. Review of systems otherwise negative.

Exam:
CV: Regular rate rhythm S1-S2 no murmurs auscultated
Lungs: Bilaterally clear to ausculation
Extremeties:Negative for edema

Assessment/Plan
724.5 Backache Unspec
Rx Norco 7.5/325mg one by mouth every 4-6 hours #120 no refills
Followup pain management
Other medications refilled
Return to clinic in one month for narcotic followup

Also contained within in the note are medications that have been added, renewed or discontinued.

The dispute it whether the exam was appropriate/extensive enough for this visit.

Any assistance with this is greatly appreciated.

Thanks!

Technically, there's enough documentation listed to support a lower-level E/M code. If I were auditing this, though, I would advise the provider that the lack of any Musculoskeletal exam, is troubling, since that is the focus of the Chief Complaint.

According to CMS:
"The levels of E/M services are based on four types of examination:
❖ Problem Focused – A limited examination of the affected body area or organ system;
❖ Expanded Problem Focused – A limited examination of the affected body area or
organ system and any other symptomatic or related body area(s) or organ system(s);
❖ Detailed – An extended examination of the affected body area(s) or organ system(s)
and any other symptomatic or related body area(s) or organ system(s); and
❖ Comprehensive – A general multi-system examination or complete examination
of a single organ system (and other symptomatic or related body area(s) or organ
system(s) – 1997 documentation guidelines).
An examination may involve several organ systems or a single organ system. The type
and extent of the examination performed is based upon clinical judgment, the patient's
history, and nature of the presenting problem(s)...

Some important points that should be kept in mind when documenting general
multi-system and single organ system examinations (in both the 1995 and the 1997
documentation guidelines) are:
❖ Specific abnormal and relevant negative findings of the examination of the
affected or symptomatic body area(s) or organ system(s) should be documented.
A notation of “abnormal” without elaboration is not sufficient.
❖ Abnormal or unexpected findings of the examination of any asymptomatic body
area(s) or organ system(s) should be described.
❖ A brief statement or notation indicating “negative” or “normal” is sufficient to
document normal findings related to unaffected area(s) or asymptomatic organ
system(s)." [http://www.cms.gov/Outreach-and-Edu...downloads/eval_mgmt_serv_guide-ICN006764.pdf]

Given that this is a chronic problem, I can see how the provider might not think it's necessary to perform a detailed examination of the patient's back (eg, examining the Range of Motion, strength/stability, etc.). But, the HPI documented doesn't provide a lot of clues as to the severity of the pain, any modifying factors, timing, and there's very little context. So, the note would probably hold up, based on the amount of documentation, alone, but I would advise him to include more relevant documentation (to the presenting problem), in the future, to better reflect medical necessity, and to better support the quality of care that he's providing. Hope that helps!