Wiki Who's responsible for determining complexity of problems addressed?

[Queizati]

Our physicians see many patients for common musculoskeletal issues such as:

tendonitis
muscle trigger points
trigger fingers
radiculopathy
impingement syndrome
carpal tunnel
myofacial pain
trochanteric pain syndrome
bursitis

Is it the coder's job to determine whether these conditions may last up to a year or until the patient's death (chronic) and if the risk of morbidity is low/moderate/high?

From what I've read into these conditions, most should improve over time with rest, ice/heat, OTC medications, and other conservative measures.

I'm having trouble determining if these conditions fall into low or moderate complexity of a problem. The definitions provided in the low complexity problems mention "problems that runs a definite and prescribed course", "A recent or new short-term problem with low risk of morbidity for which treatment is considered" and "problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course".
illness."

Our physicians always consider treatment, do further workup by way of ordering imaging, provide symptom management and counseling, and follow up with the patient. Saying these conditions are self-limited or minor according to those descriptions doesn't feel like giving enough credit.

I will post 3 case examples in a reply to follow.

 

[Queizati]

1) Patient presents for evaluation of left shoulder pain. The pain first started 2 1/2 weeks ago after a fall onto the left shoulder. Since then, the pain is better.
Severity: 8/10
Timing: always present with varying intensity
Quality: pulsating
Modifying factors: alleviated by nothing and exacerbated by carrying heavy objects

Imaging: independent interpretation of shoulder x-rays

AP: Pt with shoulder pain after fall likely due to AC joint pathology

Plan: Discussed with the patient possible treatment options including physical therapy, medications (topical and/or oral), injections, neuromodulation, and surgery. Treatment plan agreed upon: gradual return to activities, continue tylenol as needed, and physical therapy referral.​

2) Patient presents for evaluation of right knee pain. Patient complaints began without inciting incident in 2018 and symptoms more noticeable in the last few months. Has a history of bony spur procedure in 2016 to the suprapatellar.
Quality: tight below-knee pain
Associated symptoms: redness, swelling, locking, buckling
Severity: 2/10 currently, 6/10 at its worst
Modifying factors: knee extension, no issues with stairs or walking
Alleviated with rest and occasional ibuprofen
Patient has not tried any conservative measures such as PT, yoga, chiropracty, injections.

Imaging: independent interpretation of BL knee xrays

AP: - chronic right proximal patellar tendinopathy
-Right gluteus medius tendinopathy + core dysfunction

Plan: patient was counseled on optimal diet and lifestyle management. Start PT, cool compress/ warm heat, start OTC 600 mg ibuprofen for inflammation. Follow up 6-8 weeks

3) Patient presents for evaluation of right ankle pain. Had an inversion injury 1.5 weeks ago when he rolled his ankle during fencing. Had immediate pain after but was able to bear weight. Next day developed localized swelling and ecchymosis. Had trouble walking long distances and lunging. Pain rated 1/10. Has been wearing a compression sleeve and doing some PT. OTC Advil taken with some relief.
Bedside US was performed with suspected high-grade tears of both CFL and ATFL.
Imaging: independent interpretation of ankle x-ray

AP: -Right acute traumatic lateral ankle sprain, grade II-II
-Right gluteus medius tendinopathy

Plan: Advised lace-up ankle brace
Referral to physical therapy for ankle stability,
Rest, ice, compression and elevation for swelling
MRI indicated given acute injury with significant swelling and suspected high grade tears of both CFL and ATFL
OTC Advil

 

[jkyles]

Hi there, the treating provider, and not the coder is responsible for making clinical decisions.

When a coder disagrees with the level the treating provider indicates that should prompt a conversation between the coder and the provider. In this case you might review the general guidelines and the guidelines and descriptors for the category with the provider using the examples you provided to explain why you think the level should be different.

Every encounter is going to involve a certain amount of work and as the guidelines state there isn't always a direct correlation between total amount of work done and the complexity of the problem addressed. I'd also note that if you think the providers are spending a lot of time on each visit and not getting full credit for their work, time-based billing is always an option.

 

[Queizati]

Hi there, the treating provider, and not the coder is responsible for making clinical decisions.

When a coder disagrees with the level the treating provider indicates that should prompt a conversation between the coder and the provider. In this case you might review the general guidelines and the guidelines and descriptors for the category with the provider using the examples you provided to explain why you think the level should be different.

Every encounter is going to involve a certain amount of work and as the guidelines state there isn't always a direct correlation between total amount of work done and the complexity of the problem addressed. I'd also note that if you think the providers are spending a lot of time on each visit and not getting full credit for their work, time-based billing is always an option.

Thank you for your feedback. I'm feeling a lot of doubt about my "judgement' in determining the complexity of the problems so I wanted to get some opinions on what others thought before approaching the provider; I'm worried about these visits being over-coded than what is supported. It's an area I would like to improve on but is a lot more circumstansial and nuanced than the other two categories of MDM.