Wiki Why was I marked wrong? (Practicode Case ID: OPD7478)

[Elund]

The documentation:

Spoiler

OFFICE - ESTABLISHED

SEX: FEMALE

AGE: 69

DOS: 1/1/20XX

CHIEF COMPLAINT: Left shoulder problem. Left shoulder pain x 2 weeks.

HPI:


Shoulder. Reported by patient. Hand Dominance: right. Location: left; anterior. Quality: aching. Severity: pain level 7/10; worst pain 9/10. Duration: 2 weeks. Timing: chronic. Context: cannot identify. Alleviating Factors: lifting; carrying; pushing/pulling. Associated Symptoms: no weakness; no numbness; no catching/locking; no grinding; no fever. Previous Surgery: none. Previous Injections: none. Previous PT: none. Work Related: no. Working: no.


PROBLEMS: Problems Not Reviewed (last reviewed 1/21/20XX).


• Niddm controlled


• Obesity


• Anxiety


• Hypertension controlled


• Pain in joint – shoulder


ALLERGIES: Reviewed Allergies: NKDA.


MEDICATIONS: Reviewed Medications:


ACETAMINOPHEN 300 MG


ADVAIR DISKUS 500 MCG-50


ALBUTEROL SULFATE HFA 90 MCG


AMPICILLIN 500 MG CAP


CARVEDILOL 12.5 MG TAB


COREG 25 MG TAB


DILTIAZEM ER 180 MG CAP


EFFEXOR XR 75 MG


KETOROLAC 60 MG ORAL


LEVOFLOXACIN 500 MG TAB


LISINOPRIL 20 MG


METFORMIN 1,000 MG TAB


METOLAZONE 5 MG TAB


METOPROLOL SUCCINATE ER 50 MG


MOBIC 15 MG TAB


PENICILLIN C POTASSIUM 500 MG TAB


SIMVASTATIN 20 MG TAB


SOMA 350 MG TAB


SULFAMETHOXAZOLE 800 MG


TAZTIA XT 360 MG CAP


SOCIAL HISTORY: Reviewed Social History: Family Practice: Smoking Status: never smoker.


PAST MEDICAL HISTORY: Reviewed Past Medical History.


FAMILY HISTORY: Reviewed Family History. Non-contributory.


SURGICAL HISTORY: Reviewed Surgical History.


GYN HISTORY: Reviewed GYN History.


OBSTETRIC HISTORY: Reviewed Obstetric History.


VITALS: Height: 5’2”. Weight: 206 lbs. BMI: 37.7. BP: 136/90 sitting L arm. Pulse: 93 bpm regular. RR: 18. O2Sat: 97% Room Air. Pain Scale Type: numeric. Pain Scale: 5.


ROS: Patient reports muscle aches and arthralgias/joint pain. She reports no fever, no night sweats, and no significant weight gain. She reports no ear pain. She reports no sore throat. She reports no chest pain and no shortness of breath when walking. She reports no cough and no shortness of breath. She reports no abdominal pain, no diarrhea, and not vomiting blood. She reports no jaundice and no rashes. She reports no fatigue.


PHYSICAL EXAM: Patient is a 69-year-old female.


CONSTITUTIONAL: General Appearance: NAD and overweight.


PSYCHIATRIC: Orientation: to time, place, and person. Mood and Affect: normal mood and affect and active and alert.


CARDIOVASCULAR SYSTEM: Arterial Pulses Right: radial normal and brachial normal.


C-SPINE/NECK: Active Range of Motion: flexion normal and extension normal.


SHOULDERS: Inspection Right: no misalignment, atrophy, erythema, swelling, or warmth. Inspection Left: no misalignment or atrophy. Bony Palpation Right: tenderness to anterior aspect L shoulder; pain with resisted abduction and overhead movement.


SKIN: Right Upper Extremity: normal. Left Upper Extremity: normal.

BASIC CARDIO PE: Lungs: clear to auscultation. Cardio: no murmurs. Abdomen: soft. Extremities: no edema.

ASSESSMENT/PLAN:

DM II

PAIN IN JOINT; SHOULDER REGION.

• KETOROLAC (Toradol) IM Injection 60 MG

DISCUSSION: Ketorolac (Toradol) injection 60 mg. IM today pt counseled; no steroids due to her diabetes; OTC muscle rubs and Advil/ibuprofen prn; f/u 2 wks. for diabetic check.

Return to Office: To see Anne Smith, APRN-CNP on 8/1/20XX. To see Dr. Jones on 9/1/20XX.

John Jones, MD

Electronically signed by JOHN JONES, MD 1/1/20XX

Why aren't the obesity and BMI coded?

 

[sls314]

The documentation:

Spoiler

OFFICE - ESTABLISHED

SEX: FEMALE

AGE: 69

DOS: 1/1/20XX

CHIEF COMPLAINT: Left shoulder problem. Left shoulder pain x 2 weeks.

HPI:


Shoulder. Reported by patient. Hand Dominance: right. Location: left; anterior. Quality: aching. Severity: pain level 7/10; worst pain 9/10. Duration: 2 weeks. Timing: chronic. Context: cannot identify. Alleviating Factors: lifting; carrying; pushing/pulling. Associated Symptoms: no weakness; no numbness; no catching/locking; no grinding; no fever. Previous Surgery: none. Previous Injections: none. Previous PT: none. Work Related: no. Working: no.


PROBLEMS: Problems Not Reviewed (last reviewed 1/21/20XX).


• Niddm controlled


• Obesity


• Anxiety


• Hypertension controlled


• Pain in joint – shoulder


ALLERGIES: Reviewed Allergies: NKDA.


MEDICATIONS: Reviewed Medications:


ACETAMINOPHEN 300 MG


ADVAIR DISKUS 500 MCG-50


ALBUTEROL SULFATE HFA 90 MCG


AMPICILLIN 500 MG CAP


CARVEDILOL 12.5 MG TAB


COREG 25 MG TAB


DILTIAZEM ER 180 MG CAP


EFFEXOR XR 75 MG


KETOROLAC 60 MG ORAL


LEVOFLOXACIN 500 MG TAB


LISINOPRIL 20 MG


METFORMIN 1,000 MG TAB


METOLAZONE 5 MG TAB


METOPROLOL SUCCINATE ER 50 MG


MOBIC 15 MG TAB


PENICILLIN C POTASSIUM 500 MG TAB


SIMVASTATIN 20 MG TAB


SOMA 350 MG TAB


SULFAMETHOXAZOLE 800 MG


TAZTIA XT 360 MG CAP


SOCIAL HISTORY: Reviewed Social History: Family Practice: Smoking Status: never smoker.


PAST MEDICAL HISTORY: Reviewed Past Medical History.


FAMILY HISTORY: Reviewed Family History. Non-contributory.


SURGICAL HISTORY: Reviewed Surgical History.


GYN HISTORY: Reviewed GYN History.


OBSTETRIC HISTORY: Reviewed Obstetric History.


VITALS: Height: 5’2”. Weight: 206 lbs. BMI: 37.7. BP: 136/90 sitting L arm. Pulse: 93 bpm regular. RR: 18. O2Sat: 97% Room Air. Pain Scale Type: numeric. Pain Scale: 5.


ROS: Patient reports muscle aches and arthralgias/joint pain. She reports no fever, no night sweats, and no significant weight gain. She reports no ear pain. She reports no sore throat. She reports no chest pain and no shortness of breath when walking. She reports no cough and no shortness of breath. She reports no abdominal pain, no diarrhea, and not vomiting blood. She reports no jaundice and no rashes. She reports no fatigue.


PHYSICAL EXAM: Patient is a 69-year-old female.


CONSTITUTIONAL: General Appearance: NAD and overweight.


PSYCHIATRIC: Orientation: to time, place, and person. Mood and Affect: normal mood and affect and active and alert.


CARDIOVASCULAR SYSTEM: Arterial Pulses Right: radial normal and brachial normal.


C-SPINE/NECK: Active Range of Motion: flexion normal and extension normal.


SHOULDERS: Inspection Right: no misalignment, atrophy, erythema, swelling, or warmth. Inspection Left: no misalignment or atrophy. Bony Palpation Right: tenderness to anterior aspect L shoulder; pain with resisted abduction and overhead movement.


SKIN: Right Upper Extremity: normal. Left Upper Extremity: normal.

BASIC CARDIO PE: Lungs: clear to auscultation. Cardio: no murmurs. Abdomen: soft. Extremities: no edema.

ASSESSMENT/PLAN:

DM II

PAIN IN JOINT; SHOULDER REGION.

• KETOROLAC (Toradol) IM Injection 60 MG

DISCUSSION: Ketorolac (Toradol) injection 60 mg. IM today pt counseled; no steroids due to her diabetes; OTC muscle rubs and Advil/ibuprofen prn; f/u 2 wks. for diabetic check.

Return to Office: To see Anne Smith, APRN-CNP on 8/1/20XX. To see Dr. Jones on 9/1/20XX.

John Jones, MD

Electronically signed by JOHN JONES, MD 1/1/20XX

Why aren't the obesity and BMI coded?

Obesity wasn't diagnosed or assessed, so there's no reason to code it.

The only mention of obesity is in the Problem List, which wasn't reviewed at this visit. Note that the last date the problem list was reviewed was 1/21/20XX. This note's DOS was 1/1/20XX, which means that notation of Obesity on the problem list was at least a year ago.

Nothing indicates that Obesity is still a current diagnosis, and the physician only mentions Overweight in the physical exam at today's visit.

 

[Elund]

Obesity wasn't diagnosed or assessed, so there's no reason to code it.

The only mention of obesity is in the Problem List, which wasn't reviewed at this visit. Note that the last date the problem list was reviewed was 1/21/20XX. This note's DOS was 1/1/20XX, which means that notation of Obesity on the problem list was at least a year ago.

Nothing indicates that Obesity is still a current diagnosis, and the physician only mentions Overweight in the physical exam at today's visit.

The BMI was provided in the vitals as 37.7. Isn't that sufficient to code for obesity?

 

[sls314]

The BMI was provided in the vitals as 37.7. Isn't that sufficient to code for obesity?

Coders cannot interpret and diagnose conditions. You can only code it if the provider diagnoses it.

Edit to add: Don't forget the physician specifically stated "overweight" in the physical exam for this visit, not obese.

 

[LAT93]

Coders cannot interpret and diagnose conditions. You can only code it if the provider diagnoses it.

Edit to add: Don't forget the physician specifically stated "overweight" in the physical exam for this visit, not obese.

I agree with the first sentence. Is there any resources that you can provide? It would help a lot in our coder meeting and meeting with providers. Thank you!

 

[CBLENNIE]

Couldn't the DX for "overweight" be coded E66.3 since it was specifically noted in the ROS under Constitutional? Just playing devils advocate here.

 

[iowagirl77]

If it isn't being treated, and is not required by another code, such as 'code also', you shouldn't code it. It may be in the problem list, but it is not in the assessment.

 

[Elund]

What confuses me is that sometimes I'm expected to code info such as obesity, hypertension, sleep apnea, CPAP, long term use of aspirin, long term use of anticoagulants, etc. when they are provided in the problem list but not in the diagnosis or clinical impression (whether or not the condition is being directly treated or required via "code also"), and sometimes I'm not. Also, the CPC class that I took (from AAPC) said that I should look through the body of the documentation instead of relying on the physician to list every condition or procedure that should be coded within the post-operative diagnosis, procedures, or clinical impression.