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You are here: Home / Articles / Coding Corner Answer

Coding Corner Answer

November 1, 2008 • By From the College

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This history level is headed in the direction of a level-four visit if the documentation for either the examination or medical decision making is strong enough. Remember, it also could drop down to a level-three visit if the documentation is not strong enough in the two other sections of the evaluation and management visit.

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Getting to This Answer: The history of present illness has six elements:

  • Modifying factors: The patient is on celecoxib, methotrexate, folic acid, and lansoprazole.
  • Severity: The patient reports pain to be moderate.
  • Location: The pain is in her wrists and finger joints.
  • Timing: She reports generalized morning stiffness for one to three hours.
  • Associated signs and symptoms: The patient fatigues easily.
  • Duration: The patient has swelling and stiffness every day.

The review of systems has seven elements:

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  • Gastrointestinal: The patient denies dyspepsia or abdominal complaints.
  • Hematologic/Immunologic: She denies fever, Raynaud’s phenomenon, and hematochezia.
  • Cardiovascular: The patient denies chest pain.
  • Respiratory: She denies dyspnea and cough.
  • Ears, nose, mouth, and throat: The patient denies oral ulcers.
  • Integumentary: The patient denies rashes.
  • Psychological: She denies insomnia and depression.

Her family and social history has two elements:

  • Past medical history: The patient has a history of GERD.
  • Social history: She is married with two children.

This encounter is an established-patient outpatient visit. This history level is detailed:

  • The history of present illness is extended because there were six elements.
  • The review of systems was extended because there were seven elements.
  • The past family and social history was extended because there were two elements.

Filed Under: Billing/Coding, From the College, Practice Management Tagged With: Billing, Coding, Evaluation, Rheumatoid arthritisIssue: November 2008

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