jnieto625
Networker
New patient came in with HTN, Dry mouth, Depression & stated she was previously diagnosed with impaired fasting glucose. After physician reviews the labs patient brought in from October (5 months prior), she determines patient has diabetes not impaired fasting glucose (A1c was 6.6, glucose 102). Physician coded a 99205. I have a comprehensive Hx and comprehensive exam. However, looking at MDM, I come up with Moderate complex. While I have an extensive # of dx or treatment options, the complexity data is minimal (labs reviewed, labs ordered to be done in 4 months) and the risk is moderate based on the documentation. The physician's argument is that the patient stated she had impaired fasting glucose but based on her October labs, she feels it is diabetes and considers this severe exacerbation. My argument is that we don't know if the disease has exarcerbated because no A1c or glucose was done in the office to see if the condition worsened. She also did not prescribe any medications. This was the plan documented:
RECOMMENDATIONS: a daily aspirin, adherance to a 1200 calorie ADA diet, 5 pound weight loss, HgbA1C level checked quarterly, urine microalbumin test yearly, LDL cholesterol test yearly, daily foot self-inspection, lower blood pressure, yearly dental exams, annual eye exams, need for yearly flu shots, and pneumovax vaccination every 5 years.
REFERRALS: Referral initiated to a nutritionist ( Elizabeth Hutchins; for evaluation of DM ).
FOLLOW-UP: Schedule a follow-up visit in 4 months.
COUNSELING: The patient was counseled concerning the relationship between diabetes control and macrovascular disease including cardiovascular, cerebrovascular and peripheral vascular disease. The patient was counseled concerning the relationship between diabetes control and retinopathy, nephropathy, and neuropathy. Advised as to the targets of pre-meal glucoses (80-120 mg/dl) and postmeal glucoses (<140-160 mg/dl) Home glucose testing discussed.
All other diagnoses treated that day were stable and refills were given for medications. Any input would be greatly appreciated.
RECOMMENDATIONS: a daily aspirin, adherance to a 1200 calorie ADA diet, 5 pound weight loss, HgbA1C level checked quarterly, urine microalbumin test yearly, LDL cholesterol test yearly, daily foot self-inspection, lower blood pressure, yearly dental exams, annual eye exams, need for yearly flu shots, and pneumovax vaccination every 5 years.
REFERRALS: Referral initiated to a nutritionist ( Elizabeth Hutchins; for evaluation of DM ).
FOLLOW-UP: Schedule a follow-up visit in 4 months.
COUNSELING: The patient was counseled concerning the relationship between diabetes control and macrovascular disease including cardiovascular, cerebrovascular and peripheral vascular disease. The patient was counseled concerning the relationship between diabetes control and retinopathy, nephropathy, and neuropathy. Advised as to the targets of pre-meal glucoses (80-120 mg/dl) and postmeal glucoses (<140-160 mg/dl) Home glucose testing discussed.
All other diagnoses treated that day were stable and refills were given for medications. Any input would be greatly appreciated.