Documentation Dissection - AAPC

1 1 Documentation DissectionCOPD Insomnia Back painChief Complaint: Follow-up appt for 62-year-old female COPD coughing more, insomnia follow up, meds working ok. Today she c/o severe back pain no injury recall |1|. Acute : ACUTE ORTHOPEDIC : Thoracic Right |2|; Quality: Sharp Stabbing |3|; Severity: Moderate |4|; Duration: 5 day/s |5|; Timing: Constant; Modifying factors: Worse with cough, deep breath; Associated signs and symptoms: No of chronic conditions |6|:Major Problem List:INSOMNIA using temazepam for sleep and it is working OK overall |6|.RESTLESS LEG SYNDROME |6| |7|.EMPHYSEMA continues to have marked shortness of breath |6| |7|. Using Oxygen continuously at this point |6|.Coughing more than baseline but is trying not to cough due to pain above |6|.PERS HX OF TOBACCO USE CHRONIC OBSTRUCTIVE PULMONARY DISEASE |6|.Objective:Vital Signs: Bp: 118/62, Left Arm, Pulse: 76, Height: 5 3 , Weight: 156 lbs.

2 |8|Respiratory/Chest: Minimal air movement. Wheezes diffusely |8|.Cardiovascular: Regular rate and rhythm without murmur or abnormal heart sounds, gallops or rubs |8|.Musculoskeletal: Spine: thoracic Inspection/Palpation: Tender to palpation in paravertebral muscle mass in upper thoracic spine right |8|.Pulse Ox is 96%. Normal reading. |9|Diagnosis:Acute Chest Pain |10|Insomnia |10|COPD with mild exacerbation, emphysema |10|Plan:Patient Instructions |11|Continue current medication(s) at same dose |11|Follow-up/Return to Clinic (RTC) |11|Primary care follow-up interval recommended at last visit: March 20XX |11|Rx: PREDNISONE 5MG TAB AS DIRECTED for 9 days, 18 TABS, Ref: 0Rx: DIAZEPAM 5MG 1 TAB three times daily PRN for 10 days, 30 TAS, Ref: 02Rx: TEMAZEPAM 30MG 1 TAB at bedtime, 30 TAB, Ref: 6Rx: SYMBICORT 160 PUFFS twice dally, 120, Ref: 6_____|1| Established patient with chronic conditions.

3 |2| Location.|3| Qua l it y.|4| Severity.|5| Duration.|6| Past Medical History Social history tobacco use.|7| Review of systems: Respiratory, Musculoskeletal.|8| Exam 4 systems Expanded Problem Focused.|9| Pulse oximetry was performed.|10| Acute problem, 2 chronic conditions.|11| Drug CPT and ICD-10-CM codes are reported? CPT Codes: 99214-25, 94760 ICD-10-CM Codes: R 0 7. 9, J4 4 .1, G 4 7. 0 0 , Z 8 7. 8 91 Rationales:CPT : The note documents an office visit for an established patient for evaluation of COPD with increasing cough, Insomnia, and complaints of chest pain indicating the presenting problem is of moderate severity. A detailed history with 4 HPI, 2 Review of systems, and 2 PFSH, expanded problem focused physical examination was performed documenting four organ systems or body areas with notation of elements for each system area selected. The treatment plan details medication maintenance, and an exacerbation of COPD with acute chest the Alphabetic Index look for Evaluation and Management/Office and Other Outpatient which directs you to code range 99201 99215.

4 Reviewing the key components in the code descriptions, CPT 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; an expanded problem focused examination; and medical decision making of moderate complexity is the appropriate code selection. Verify code note also documents a pulse oximetry study was performed by the provider. In the Alphabetic Index look for Pulmonary/Diagnostic/Oximetry/Ear or Pulse which directs the coder to 94760 94762. Code 94760 indicates noninvasive ear or pulse oximetry for oxygen saturation; single determination. 94761 is used to report multiple determinations, such as during exercise. Code 94762 is reported when continuous overnight monitoring occurs. The appropriate code selection based on the Documentation is CPT code 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination.

5 Verify selection in the numeric section. Medicare bundles 94760 into a same day service and it would not be billable for a Medicare patient. The patient is 62 and not stated to be on 25 is needed on 99214 to show that the E/M visit was totally separate from the pulse - CM: The final diagnostic statement is Acute Chest Pain, Insomnia, and COPD with mild exacerbation, Emphysema. In the ICD-10-CM Alphabetic Index look for Pain/chest which directs Chest pain, unspecified. The chest pain is not documented as a symptom of the COPD. Documentation does not state the chest pain is due to the cough, but that it makes it , in the Alphabetic Index look for Disease/pulmonary/chronic obstructive/with exacerbation (acute) leads to An Excludes1 for J44 excludes Emphysema (J43) and it will not be separately in the ICD-10-CM Alphabetic Index look up Insomnia which directs to Insomnia, is an instructional note at J44 that states to use additional code to identify tobacco use, dependence, history of tobacco use or exposure to.

6 In this case the Documentation supports that the patient was a former smoker and this will be coded in addition. In the ICD-10-CM Alphabetic Index look up History/personal/nicotine dependence which directs the coder to Verify selection in the Tabular List.