Diagnoses: 714.0 and 530.81
Justification: This encounter was an established patient outpatient visit that included:
- Detailed history: HPI six elements, extended ROS, social history, and impact on functioning addressed;
- Comprehensive examination: Nine systems with complete musculoskeletal examination; and
- Moderate complexity decision making: One chronic problem worsening (rheumatoid arthritis) and one additional stable chronic problem (GERD), additional laboratory and radiologic studies ordered, and prescription drug therapy with moderate risk of significant side effects.
Note: Many rheumatologists have asked what it takes to get to a level-five visit. This visit could possibly have been a level five if the time had been documented. According to the CPT manual, a typical level-five visit would take 40 minutes. There is a rule that states if the counseling and/or coordination of care is more than 50 percent of the visit, time becomes the controlling factor of the visit. For example, if a rheumatologist has seen the patient for 45 minutes and has spent 25 minutes of that visit discussing care—such as drug reactions, side effects, and other drug interactions—the time would drive the level of the visit. However, to reach this level, the practice must document what was discussed and how long it was discussed in the patient’s medical records.