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The Documentation
Subjective
Five y/o established patient here for runny nose and sore throat. Mom is with patient. Symptoms present for three days. No fever, cough, or rash. No other complaints. Mom would like COVID testing since patient had an exposure at daycare.
Past Medical History: None
Current Medications: None
No Known Drug Allergies
Objective
Alert child sitting in mom’s lap. Temp- 98.0, HR 128, RR 26, SPO2 98%
HEENT: No corneal injection, TMs clear, oropharynx is erythematous but no exudates. PND noted.
Neck: supple, no adenopathy
Lungs: CTAB, No rhonchi or wheezing
Heart: Tachy rate, No murmur
Recent results
Collection time: 08/24/22 11:18 AM
POCT rapid Covid is negative
Assessment
URI
Exposure to COVID
Plan
Orders Placed in This Encounter: POCT COVID test
Facility-Administered Encounter Medications: None
Medications Prescribed During This Encounter: None
Discussion
We will break this case down by referring to the MDM Elements:
Number and Complexity of Problems Addressed
The patient complaint is a runny nose and a sore throat. This would fall under “1 acute, uncomplicated illness or injury”, which is a “Low” MDM or Level 3.
Amount and/or Complexity of Data to be Reviewed and Analyzed
In this case, the provider ordered a POCT COVID. This would count towards 1 “ordering of each unique test” in Category 1.
The provider did not document that the mother provided the HPI, therefore one point for independent historian would not be awarded. This meets the criteria for straightforward, which is Level 2.
Risk of Complications and/or Morbidity or Mortality of Patient Management
No prescriptions were sent to the pharmacy. The provider did not document recommendations for the patient to take OTC medications. This would be straightforward or Level 2.
Two of the three elements of MDM need to be met when choosing your level of service. We successfully met Level 3 for problems addressed but only straightforward, Level 2 for data and risk. Unfortunately based on the documentation provided, the correct E/M code is a 99212.
Discussion
What if the provider had documented he/she used an independent historian, in this case the mother, to gather the HPI? This would have increased the LOS to a 99213 since the Complexity of Data Category 1 “low” requirement would be met. Data Category 2 would also be met, and we only need one of the two.
What if the provider had documented that the patient should take OTC medications such as ibuprofen and dextromethorphan for their symptoms? If he/she had, this would increase the risk to a “low” Level 3, also increasing the LOS to 99213.
This case illustrates the need for proper documentation of OTC meds and independent historian which in many cases, may be the difference between Level 2 and 3 billing.