99215

The below is a note that was billed as a 99215. I was under the impression that in order to get high complexity medical decision making, typically the patient is having a severe exacerbation of a condition, an illness or injury that poses a threat to life or bodily function or an abrupt change in neurologic status, etc. However, I have many providers that believe complicated cases like the one below warrant a level 5 visit. I am curious what other auditors would code this visit as and what your thoughts are on coding 99215's for these types of complicated cases.
83-year-old white female who has advanced dementia. She is followed by the Summit 1 clinic. Patient also has a history of diastolic congestive heart failure with ejection fraction of 60%. She does have bilateral nephrolithiasis and has had problems with hydronephrosis and has had stenting done by her urologist. Patient has recurrent urinary tract infections. She's been hospitalized on number occasions. Generally this causes her to have problems with confusion. She has a decubitus on her back that the family. She is followed recently by home health but not currently she has hypertension follows a low-sodium diet she does have problems with pruritic nodularis and is followed by her dermatologist she picks at her skin. She's had renal artery stenosis followed by her vascular surgeon she's had stenting of her renal arteries. She has had varicose vein she has vitamin D deficiency. She's nutritionally 1 depleted. She does have problems coughing after she eats which is suspicious that she may be having some aspiration she will be referred to speech therapy for this. She does have problem restless leg syndrome. She has difficulty taking her medication she has some diarrhea since she's had her gallbladder removed. She is hypothyroid on thyroid replacement she is hyperlipidemic. She does ambulate with assistance. She knows her children. She does have an essential tremor. We reviewed her medications and a laminated several medications of magnesium for her to swallow them. We will add Zenifoam to help manage her sacral decubitus.

Review of Systems
Constitutional: fatigued, but no night sweats. Eyes: no vision changes and no purulent discharge from the eyes.
ENT: no nasal congestion and no nasal discharge. Cardiovascular: no chest pain, no palpitations and no lower extremity edema. Respiratory: dyspnea on exertion
The patient presents with complaints of cough, described as loose. Pertinent Medical History: congestive heart failure. Gastrointestinal: diarrhea and dysphagia, but no nausea and no vomiting. Genitourinary: dysuria, urinary frequency and incontinence. Musculoskeletal: arthralgias and joint stiffness.
Integumentary: skin rash and itching. Neurological: dizziness, but no headache.
Psychiatric: no anxiety and no depression. Hematologic/Lymphatic: a tendency for easy bruising, but no tendency for easy bleeding.

Physical Exam
Constitutional
General appearance: chronically ill, uncomfortable, underweight and appears tired. Head and Face Head and face: Atraumatic, normocephalic.
Palpation of the face and sinuses: No sinus tenderness.
Eyes
Conjunctiva and lids: No erythema, swelling or discharge.
Pupils and irises: Equal, round, reactive to light, sclera anicteric.
Ears, Nose, Mouth, and Throat
Lips, teeth, and gums: No dental problems observed.
Oropharynx: Normal with no erythema, edema, exudate or lesions.
Neck: Supple, symmetric, trachea midline, no masses.
Thyroid: No thyromegaly, tenderness or palpable nodules.
Pulmonary
Respiratory effort: No increased work of breathing or signs of respiratory distress. Auscultation of lungs: Auscultation of the lungs revealed bibasilar rales/crackles. Cardiovascular Auscultation of heart: Regular rate and rhythm without murmurs, rubs, or gallops. Palpation of heart: Normal PMI, no thrills.
Examination of extremities for edema: No significant edema.
Chest
Chest: No chest wall deformity.
Abdomen
Abdomen: Soft, non-tender, non-distended, no masses and normal bowel sounds.
Liver and spleen: No hepatomegaly or splenomegaly.
Lymphatic
Palpation of lymph nodes in neck: No lymphadenopathy.
Palpation of lymph nodes in axillae: No lymphadenopathy.
Skin
Skin and subcutaneous tissue: Normal without rashes or lesions.
Palpation of skin and subcutaneous tissue: Normal turgor.
Musculoskeletal
Inspection/palpation of joints, bones, and muscles: No significant contractures or deformities. Inspection/palpation of digits and nails: Normal without clubbing or cyanosis Neurologic Muscle strength/tone: Tremor(s): right upper extremity resting tremor and left upper extremity resting tremor. Cranial nerves: Cranial nerves 3-12 intact. Coordination: Coordination: impaired balance.
Psychiatric
Judgment and insight: Judgment: impaired judgment and impaired insight.
Mood and affect: Normal.

Assessment
1. Benign essential hypertension (401.1) (I10) 2. Calculus of kidney (592.0) (N20.0) 3. Compression fracture of L1 lumbar vertebra with routine healing (V54.17)
(S32.010D)
4. Decubitus ulcer of back, stage 2 (707.09,707.22) (L89.102) 5. Dementia (294.20) (F03.90) 6. Gait disturbance (781.2) (R26.9) 7. Hydronephrosis, bilateral (591) (N13.30) 8. Hypothyroidism (244.9) (E03.9) 9. Hyperlipidemia (272.4) (E78.5) 10. Poor appetite (783.0) (R63.0) 11. Prurigo nodularis (698.3) (L28.1) 12. Psoriasis (696.1) (L40.9) 13. Renal artery stenosis (440.1) (I70.1) 14. Tremor (781.0) (R25.1) 15. Vitamin D deficiency (268.9) (E55.9) 16. Aortic calcification (440.0) (I70.0) 17. PVD (peripheral vascular disease) (443.9) (I73.9) 18. Aspiration pneumonia (507.0) (J69.0) 19. Severe protein-calorie malnutrition (262) (E43) 20. Osteoporosis (733.00) (M81.0) 21. Chronic diastolic congestive heart failure (428.32,428.0) (I50.32)

Plan
Benign essential hypertension
* Venipuncture, routine;
Vitamin D deficiency
* # CULTURE, URINE, ROUTINE (Non-CATH
* EKG, ECG, with Interpretation;
Unlinked
* Stop: Allegra 180 MG TABS (Fexofenadine HCl)
* Stop: Carvedilol 3.125 MG Oral Tablet
* Stop: Ciprofloxacin HCl - 250 MG Oral Tablet
* Stop: Donepezil HCl - 10 MG Oral Tablet (Aricept)
* Stop: Polyethylene Glycol Powder
* Stop: Sertraline HCl - 50 MG Oral Tablet
* Stop: Tamsulosin HCl - 0.4 MG Oral Capsule (Flomax)
* Start: Azelastine HCl - 0.15 % Nasal Solution; INSTILL 1 SQUIRT TWICE DAILY
* Start: Melatonin 5 MG Oral Tablet; TAKE 1 TABLET BEDTIME

Follow-up visit in 3 weeks Evaluation and Treatment Follow-up
For: Dementia;

Comprehensive Metabolic Panel, CMP;

Discussion/Summary
Hospital discharge summary reviewed, medication reconciliation performed, and medication list updated including discussion of changes. Records reviewed at this visit include: Neurology note was reviewed as well as previous hospitalizations. Patient will be tapered off of a number of her medications.
We'll see if this will influence her ability to be more active and less confused will skip the urine culture back and treat her with suppressive dosages of antibiotics. We talked to the family about wound care of her buttocks. Her restless leg syndrome will be addressed the next time she does have problems with nasal drainage and congestion we gave her an Astelin nasal spray for this she will be evaluated by speech therapy. Discussed her treatment with the pharmacist as to her medication for her sacral decubitus Other Recommendations Activity Avoid activities that cause or worsen the pain.

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