Coding Challenge Results

Here are the results of this week's coding challenge:

61% of respondents UNDERCODED this common patient complaint. Can your healthcare system afford this? Let me help! Message me on LinkedIn or schedule a consultation at medicalcodingexcellence.com

Number and Complexity of Problems Addressed

Patient complains of dysuria and vaginal discharge which would qualify as an acute, uncomplicated illness or injury. This would be "low" level 3.

Amount and/or Complexity of Data to be Reviewed or Analyzed

The following labs were ordered during the encounter: Nuswab, urine culture and a POCT UA. 3 lab tests were ordered which would meet the criteria for Category 1 in the "moderate" level 4 section.

Risk of Complications and/or Morbidity or Mortality of Patient Management

Diflucan and Macrobid were prescribed. This would be "moderate" level 4.

2 of the 3 Elements of MDM need to be met when choosing your level of service. We successfully met level 4 criteria in the Data and Risk categories, so this is a 99204!

Source: CPT E/M Office Revisions Level of Medical Decision Making (MDM). Available at www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist--administrators/billing-and-coding/cpt--em/2023-cpt-revised-mdm-grid.pdf

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23 y.o. female (new patient) presents with dysuria and vaginal discharge

This is a new problem. The current episode started in the past 7 days. The problem has been unchanged. Pertinent negatives include no abdominal pain, fever or nausea. Treatments tried: OTC yeast tabs. The treatment provided no relief.

She feels like she has a yeast infection. She notes vaginal irritation, itching and thick cottage cheese like discharge. She has had them before. She has also had bacterial vaginosis but did not notice this to have an odor. She did not have significant STD concerns but does want to get tested.

She has had dysuria also for the past 2 days. Some frequency and urgency.

Objective

BP 116/83 | Pulse 84 | Temp 98.3 °F (36.8 °C) (Oral) | Ht 5' 5" | Wt 190 lb

BMI 31.62 kg/m2

Physical Exam

Constitutional: Normal appearance. She is well-developed.

Pulmonary: Pulmonary effort is normal.

Cardiac: RRR without murmur.

Abdominal: no TTP, BSX4, No G/R/R

Genitourinary: GU exam was offered but declined

Skin: Skin is dry. Coloration: Skin is not pale.

Neurological: Mental Status: She is alert. Gait: Gait normal.

Psychiatric: Behavior normal.

UA is positive for leukocytes, nitrites, and blood.

Assessment

Acute vaginitis

Acute Cystitis

Plan

Suspect yeast clinically by symptoms. We will treat with Diflucan. Testing sent- patient will need to be contacted if further treatment is needed.

Acute cystitis- will treat with Macrobid 100mg BID for 7 days. Urine culture sent.

Orders Placed This Encounter

NuSwab Vaginitis Plus(VG+) Vaginal Vaginal

POCT Urinalysis

Urine culture