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[MidwestCoder]

A 61Y who presents today for evaluation of enlarged lymph nodes at the request of ... He first noticed them 5-6 weeks ago. There are non tender. They do fluctuate in size somewhat, but have never disappeared. He doesn't notice them restricting his ROM or when swallowing. No weight loos or appetitie changes. No previous neck problems. No sores/masses in his mouth. Patient is also anemic. Reports no still changes including no dark stools. No abdominal pain, nausea or vomiting. No blood in his stools. He doesn't notice the masses unless he pushes on them or feels his neck. No family hisotry of any colon cancer, stomach cancer, lymphomas, or esophageal cancer.

There is a comprehensive ROS and Comprehensive History, and Comprehensive exam.

Can some help please with the auditing of this HPI?

 

[01065679]

Its hard to audit something without the complete report. You are saying there is a comprehensive ROS & HPI. What about PFSH? Thats the 3rd component for the History portion. You also said there was a comprehensive Exam. What about the MDM? The MDM is really going to be the deciding factor. If the PFSH is complete (3 out of 3) Then both the history & exam are comprehensive (level 4 or 5) however if his medical decision making was of a low or moderate complexity you will have to code the level of what that is. The patient has one new problem either 3 or 4 points depending on if the doctor did any work up. Depending on what kind if any test he ordered will give him a few points in that. If he gave him prescriptions then it could possibly come out to a level 4.
Have you ever used the Medicare audit tool to choose the correct level. I am not sure what MCR you have out in the midwest but I know trailblazers, NGS and Highmark all have one.