Wiki What level E/M do you come up with?

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kjstearns

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Patient comes in for evaluation of his left knee. Patient is a 49-year-old pilot who was skiing in April and sustained an injury to his left knee.

HE HAD AN MRI SCAN because his knee feels loose, and this shows a complete ACL tear. He has medial and lateral meniscus tears, as well.

HIS EXAMINATION indicates no effusion. He has a positive Lachman and 2+ medial laxity. His right knee has a positive Lachman, as well, but it has no medial laxity.

He is able to work and do his activities of daily living, but he cannot do things that he is used to doing, and one of the hazards he has is that he does carry heavy bags up and down a couple flights of stairs in the course of his work, and there is some uncertainty as to how safe he is, and he is concerned about this.

MY FEELING is that he has an unstable left knee.

MY RECOMMENDATION is that he considers an ACL reconstruction, and possible partial medial and possible partial lateral meniscectomy and/or repair.

OUR PLAN would be to have him schedule this at his convenience. I would like to get an allograft Achilles tendon for this, as possible.


So with no ROS, and no PFSH, can I only bill a level 1??

Thanks in advance,
Kirsten
 
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kjstearns said:
Patient comes in for evaluation of his left knee. Patient is a 49-year-old pilot (SOCIAL HISTORY) who was skiing in April (CONTEXT) who sustained an injury to his left knee (LOCATION).

HE HAD AN MRI SCAN because his knee feels loose(MS ROS, arguably), and this shows a complete ACL tear. (MDM FOR REVIEW OF RAD) He has medial and lateral meniscus tears, as well.

HIS EXAMINATION indicates no effusion. He has a positive Lachman and 2+ medial laxity. His right knee has a positive Lachman, as well, but it has no medial laxity. (PF EXAMINATION-MUSCULOSKELETAL 95'S)

He is able to work and do his activities of daily living, but he cannot do things that he is used to doing, and one of the hazards he has is that he does carry heavy bags up and down a couple flights of stairs in the course of his work, and there is some uncertainty as to how safe he is, and he is concerned about this.

MY FEELING is that he has an unstable left knee.

MY RECOMMENDATION is that he considers an ACL reconstruction, and possible partial medial and possible partial lateral meniscectomy and/or repair.

OUR PLAN would be to have him schedule this at his convenience. I would like to get an allograft Achilles tendon for this, as possible.


So with no ROS, and no PFSH, can I only bill a level 1??

Thanks in advance,
Kirsten
Click to expand...

I worked this out and though I can make a case for EPF history counting knee feels loose as a MS ROS, the exam is purely MS (PF) and limits the code to 99201 if this is a new patient regardless of any argument I can make to boost the history.

That's my take. Hope it helps.
 
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