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[Orthocoderpgu]

The patient comes in with a complaint of pain and swelling in his groin.

HISTORY OF PRESENT ILLNESS:
He has had some soreness in the right scrotum and some soreness going up, into the upper part of his scrotum. He has had a chronic problem with itching of the right scrotum and has been using Tinactin. He has been scratching it a lot. Over the past couple of days, it got more painful and there was some tenderness near the upper scrotum. Last night, he started putting Neosporin on it and it seems to have improved a little bit today and the tenderness is decreased.

OBJECTIVE:
GENERAL: The patient was in no acute distress.
VITAL SIGNS: Height 5 feet 7 inches, weight 172, blood pressure 114/70, pulse 58, temperature 98.4. GU: The right scrotum had chronically thickened skin and was excoriated. There was redness on the right side and some slight edema of the skin. Near the upper scrotum, it was slightly tender to exam.

ASSESSMENT:
This patient has probably had some chronic itching and excoriation of the skin and now has a cellulitis in the skin of the scrotum. I think that this started from so much scratching and excoriation of the skin. I will start him on an antibiotic. Have him take some Zyrtec for the itching, and put a low-dose topical steroid __________ ointment on the skin, and we will follow it closely. If it worsens at all, the patient is to let me now. He will follow up with me next week and we will see how this does. If it is not responding to the cephalexin, we may need to change to trimethoprim sulfa, but we will follow this and see how it is. I will touch base with the patient tomorrow by telephone and see if it is improving.

 

[MikeEnos]

Expanded Problem Focused History
Expanded Problem Focused Exam
SF/Low Medical Decision Making Complexity
99202

You could argue that there was no system review, in which case it only qualifies as a 99201, but I gave credit for just a pertinent ROS - 1 system GU.

 

[drashby]

Mike -

Please help me learn. As you are a consultant and I consider myself new to auditing(auditing for 2 years), could you break it down for me? Using the 97 GL, I come up with 99201.

Focused Hx - Location (scrotum), duration, (couple of days), MF (neosporin and tinactin) assoc sn & sx (chronic itching) -0- ROS -0- PFSHx

Focused Exam (1 to 5 elements) Const. 2 bullets vitals and general appearance GU 1 bullet exam of scrotum skin one bullet for inspection.

Moderate MDM 1 new prob to provider, no add'l work up (3 on Marshallfield MDM WS) No data review or testing ordered and moderate risk due to Rx.

If using 95 GL I come up with Focused Hx Expanded exam ( const. GU and Skin) and Moderate MDM still arriving at 99201 due to the focused hx.

My question is, if the HPI is all pertaining to the scrotum pain, which I used for CC, how do you get a GU review of systems? Wouldn't it all be relevent to the HPI? To count a ROS for GU shouldn't something like "no pain with urination" be stated?

Thanks, in advance, for your thoughts.

 

[MikeEnos]

I counted the tenderness and scratches as a GU system review. You could also count it as integumentary I guess, but as long as you just count it once, you get a pertinent ROS. Since the HPI is extended but there is no PFSH, the History is Expanded Problem Focused.

I used '95 exam guidelines, and got an EPF exam just like you did above. I was on the fence about whether this is a self-limited/minor problem (1 point) or new problem w/ no add'l workup planned (3 points) so you may have gotten Moderate MDM whereas I came to SF/Low. Ultimately it doesn't matter, since the EPF history and exam limits us to a 99202 anyways, which only needs SF MDM.