Rheumatology Coding Corner Question: Documentation Improvement

1. A 55-year-old female patient returns for her second infliximab infusion. Her temperature is 98°F, her height is 5’6″ and her weight is 151 lbs. She received 210 mg infliximab via infusion. The patient arrived at the clinic at 8:15 a.m. and left at 10:55 a.m. Can this encounter be coded correctly?
   1. Yes
   2. No
2. A 38-year-old female patient with secondary osteoarthritis returns to the practice for her second in a series of four injections of the knee. The area was prepped in the usual sterile manner. The needle was inserted into the affected area, and the steroid was injected via ultrasound guidance. The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given. What is missing from this documentation?
   1. Indication of laterality (left or right knee)
   2. Documentation of permanent recording of the image
   3. Nothing is missing
   4. A and B
3. A 66-year-old male patient is in the office for a follow-up of his osteoarthritis. A detailed history was taken, an expanded problem exam was done, and the medical decision making was of moderate complexity. The diagnosis code billed out is M16.11. What is missing from the documentation?
   1. Type of osteoarthritis
   2. Anatomical site
   3. Location
   4. All of the above
   5. Nothing is missing
4. A 62-year-old male patient returns to the office for a follow-up visit for gout in his left foot. The patient’s present uric acid level is 4.0. Notes indicate an extended history and expanded problem-focused exam, and the medical decision making was low complexity due to limited data. The documentation of the history, exam and medical decision making would normally make this a Level 3 visit (99213). The total time for the visit was 35 minutes, but more than 50% of the visit was spent on counseling. This service is billed as 99214, and time is being used as the determining factor to bill for this level of visit. What is missing from this documentation for time as the key element?
   1. The counseling and/or coordinating care was face to face
   2. How long the counseling and/or coordinating of care was
   3. What was discussed during this counseling and/or coordinating of care
   4. A and C
   5. A, B and C
5. A patient returns for a follow-up visit for her methotrexate injection of 10 mg. What is wrong with this documentation?
   1. Nothing is missing; the documentation is complete
   2. The patient’s weight
   3. The review of systems is missing
   4. The sex of the patient
   5. The chief complaint for the follow-up visit

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