Wiki what level??

[trose45116]

would you code this as??


Chief Complaints:
1. Right knee pain.

HPI:
Appointment type:
Established patient - Established problem Patient returns for his right knee. He continues have pain in the knee. He did do some physical therapy. He did feel that this made him stronger. He denies any other complaints..

ROS:
No change from 7-31-15.

Medical History: HTN, Taking blood thinners, Coronary artery disease.

Surgical History: Knee scope , Hernia repair , Cardiac stent .

Family History:
Cancer
Heart Disease
HTN
Osteoarthritis.

Social History:
Alcohol Yes
Smoking No
Drugs No.

Medications: Taking Atorvastatin Calcium , Taking Losartan Potassium , Taking Clopidogrel Bisulfate , Taking Bystolic , Taking Aspirin , Medication List reviewed and reconciled with the patient

Allergies: PCN, Sulfa.


Objective:

Examination:
General Examination:
Evaluation of right knee reveals no erythema or signs of infection. ROM is well maintained. The knee is grossly stable to exam. Strength is full. Negative calf tenderness, negative Homan's.



Assessment:

Assessment:
1. Osteoarthritis of knee - 715.96 (Primary)

Plan:

1. Osteoarthritis of knee
Notes: I'll long discussion with the patient. He continues to do well- Weight loss. I did describe doing a Toradol injection into the right knee. He was in agreement. He was taken to the procedure room and placed in the supine position. Ultrasound was utilized. Under direct needle visualization, 15 mg of Toradol was injected into the right knee. Patient tolerated this well. All questions were answered. I'll see him back in a month.


Procedure Codes: 20611 DRAIN/INJ JOINT/BURSA W/US, J1885 INJ KETOROLAC TROMETHAMINE 15 MG

Follow Up: prn

 

[thomas7331]

I wouldn't code an office visit for this on the same day as the minor procedure without additional documentation to support a modifier 25. As a stand-along visit I'd code 99213 for an expanded history and low MDM.

 

[ndanh01]

I also agree that it is a 99213 but only because I based it on the documentation as a whole. Is it okay that the provider did not complete a review of systems and just stated no change from that date? I was under the impression that that was only acceptable for PFSH.

 

[thomas7331]

The provider may review the ROS and PFSH both from information documented by the patient or staff - ideally they should state that they reviewed and update it, but even if you disqualified that statement in this note, I think you still have enough documentation in the HPI and PFSH to give you enough ROS to support 99213. But again, I think it's non-billable as E&M due to the procedure.