what is the e/m code for this scenario? Systemic lupus erythematosus with development of edema.

Question

HISTORY OF PRESENT ILLNESS
Patient was told she had SLE in 1998.

PAST HISTORY
Illnesses: Lupoid hepatitis, 1998.
Operations: Renal biopsy. Hepatic biopsy.

REVIEW OF SYSTEMS
HEENT: Conjunctivitis and iritis.
Cardiorespiratory: Pleuritic chest pain.
Gastrointestinal: Vague abdominal pain.
Extremities: Edema.

PHYSICAL EXAMINATION
GENERAL: The patient is a 50-year-old female with obvious pedal edema.
CHEST: Heart: RRR. Lungs: Clear. Breasts: Normal.
ABDOMEN: Hepatomegaly. No shifting dullness or fluid waves.
EXTREMITIES: There was 3+ pitting edema in both lower extremities.

DATABASE
Sodium 135, potassium 4.6, calcium 7.6, phosphorus 2.7, total protein 4.5, albumin 1.9, BUN 25, creatinine 1.1, uric acid 5.2. Hemoglobin 13.6, hematocrit 42.1, sedimentation rate 35. WBCs 5600 with 86 segs, 0 bands, 12 lymphs, MCV 93. The 24-hour urine protein is 10.57 gm, creatinine 828 mg. Q-panel: The 5’-nucleotidase was elevated at 12.98, antiDNA negative, anticentromere negative, anti-smooth muscle negative, ANA positive at 195, anticardiolipin antibody normal and mitochondrial antibody normal.

ASSESSMENT
1. Abnormal antinuclear antibody positive for lupus.
2. Nephrosis.

RECOMMENDATIONS
Nephrology consultation for evaluation of renal status.

EM code

Answer 1

To determine the appropriate Evaluation and Management (E/M) code for this patient scenario, we need to consider a few key elements: the patient's history, the complexity of the medical decision-making, and the level of service provided during the encounter.

Key Elements to Consider:

1. History: The patient's history of present illness includes significant details about her condition (systemic lupus erythematosus with edema), along with relevant past medical history and review of systems.

2. Examination: The physical examination shows significant findings, such as pedal edema and hepatomegaly.

3. Complexity of Medical Decision Making:

   • Two problems are identified: systemic lupus erythematosus and nephrosis, both of which are complex conditions.
   • Laboratory results indicate abnormalities (elevated sedimentation rate, low albumin, significant proteinuria).
   • The recommendation for nephrology consultation adds to the complexity of the decision-making process.

E/M Coding Levels:

Using the 2021 guidelines for office visits (CPT codes 99201 - 99215 for established patients or 99202 - 99205 for new), we can determine the level:

• Problem-Focused (Level 1): Limited examination and straightforward medical decision making.
• Expanded Problem-Focused (Level 2): Expanded examination and low complexity.
• Detailed (Level 3): Comprehensive examination and moderate complexity.
• Comprehensive (Level 4): Extensive examination and high complexity.

Given the complexity of the patient's case, and considering the significant medical history and abnormal lab findings, the encounter likely falls under:

• New Patient E/M visit (CPT 99203 or 99204) if this is the first time the patient is seeing the provider. This includes moderate to high complexity.
• Established Patient E/M visit (CPT 99214 or 99215) if this is a follow-up visit with considerable decision-making involved.

Conclusion:

Based on the detailed assessment, it's likely that you would code this as 99204 for a new patient or 99214 for an established patient, given the complexity of the conditions being addressed and the level of decision-making involved. If full documentation supports the case, you might consider 99215 for an established patient, especially if significant time was spent on counseling and coordination of care.

Note:

Always refer to the most current coding guidelines or consult with a certified coder for confirmation, as coding can also depend on specific payer requirements or updates to regulations.