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Topic: Unit 2 Discussion – New Patient Encounter
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This is a graded discussion: 20 points possible
due Jul 20
Unit 2 Discussion – New Patient Encounter
7
12
Discussion: Unit 2, Due Wednesday by 11:59 pm CT
New Patient Encounter
Instructions:
It is anticipated that the initial discussion post should be in the range of 250-300 words.
Response posts to peers have no minimum word requirement but must demonstrate topic
knowledge and scholarly engagement with peers. Substantive content is imperative for all
posts. All discussion prompt elements for the topic must be addressed. Please proofread your
response carefully for grammar and spelling. Do not upload any attachments unless specified
in the instructions. All posts should be supported by a minimum of one scholarly resource,
ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and
references must adhere to APA format.
Classroom Participation:
Students are expected to address the initial discussion question by Wednesday of each week.
Participation in the discussion forum requires a minimum of three (3) substantive postings (this
includes your initial post and posting to two peers) on three (3) different days. Substantive
means that you add something new to the discussion supported with citation(s) and
reference(s), you are not just agreeing. This is also a time to ask questions or offer information
surrounding the topic addressed by your peers. Personal experience is appropriate for a
substantive discussion, however, should be correlated to the literature.
All discussion boards will be evaluated utilizing rubric criteria inclusive of content, analysis,
collaboration, writing, and APA. If you fail to post an initial discussion or initial discussion is
late, you will not receive points for content and analysis, you may however post to your peers
for partial credit following the guidelines above.
Initial Discussion Question/Prompt [Due Wednesday]
Consider the following questions in your initial discussion post:
Review the SOAP note accessed through this link. For purposes of the assignment, the
patient is a ‘new patient’ in the practice.
New Patient SOAP Note
(https://herzing.instructure.com/courses/26424/files/5946047/download?download_frd=1)
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Topic: Unit 2 Discussion – New Patient Encounter
Initial Post
Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’
encounter.
You may choose to assign the code based on the anticipated/guestimate amount of time the
provider would spend with the patient in the encounter or you may choose to utilize the
Medical Decision Making (MDM) approach. If you choose the MDM include the following
information in your discussion:
1. the level of history taking achieved – identify the history elements present
2. the type of exam performed – identify the number of systems and bulleted points in the
note
3. the level of medical complexity encompassed – include # of points for a)
diagnoses/management options, b) amount/complexity of data reviewed, and c) level of
risk for complications, morbidity, mortality
Responses need to address all components of the question, demonstrate critical thinking and
analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding
references in APA format.
Please review the rubric to ensure that your response meets the criteria.
Discussion Peer/Participation Prompt [Due Sunday]
Please respond to at least 2 of your peer’s posts with substantive comments using the
following steps:
Consider the knowledge you have gained from this week’s lecture.
1. Construct a response – ideally one who assigned the same CPT E&M Code that you did
and one that did not.
Substantive comments add to the discussion and provide your fellow students with
information that will enhance the learning environment.
References and citations should conform to APA standards.
Remember: Please respect the opinions of others, even if their views differ. In other
words, disagree professionally and respectfully.
Plagiarism is never acceptable – give credit when credit is due – cite your sources.
Responses need to address all components of the question, demonstrate critical thinking and
analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding
references in APA format.
Please review the rubric to ensure that your response meets the criteria. Collaboration points
will be forfeited if you fail to meet the response post guidelines.
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Topic: Unit 2 Discussion – New Patient Encounter
Estimated time to complete: 1 hour
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Benjamin Clark (https://herzing.instructure.com/courses/26424/users/29700)
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Based on the MDM model of coding I selected CPT E&M Code 99205 (new patient high
risk 60-74 minutes).
the level of history taking achieved – identify the history elements present
The history level taken from the patient is taken from the patient during the
interview. The HPI includes a detailed description of how the patient feels at the time
including exacerbating factors of home social situation with his wife and family. The history
also includes extensive important details of the patient’s relationship and the loss of his
previous wife. The history taken also included a detailed review and summation of a
traumatic episode in the patient’s past
the type of exam performed – identify the number of systems and bulleted points in
the note
The exam consisted of an interview and a series of self-reported symptoms from
the patient as well as a head-to-toe exam. The head-to-toe exam included data collected
from 9 systems; integumentary, HEENT, skin, CV, Respiratory, neurologic, GI,
musculoskeletal, and psychologic.
the level of medical complexity encompassed – include # of points for a)
diagnoses/management options, b) amount/complexity of data reviewed, and c) level
of risk for complications, morbidity, mortality
Based on a guide published by the American Society of Clinical Oncology (2022). The
diagnoses/management option level chosen for the patient was “high†or four points. This
level was chosen because the patient has at least one acute level diagnosis that poses a
threat to life. The patient is diagnosed and being treated for MDD with suicidal ideations.
The amount and complexity of data reviewed were assigned as moderate or three points.
The patient was assigned one point for labs being ordered and reviewed as well as a
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Topic: Unit 2 Discussion – New Patient Encounter
detailed summation of previous medical records/history. The level of risk for complications,
morbidity, and mortality assigned was “high”. Of the three components of the MDD method
for coding two fell into the “high” category making the overall medical complexity high.
American Society of Clinical Oncology. (2022). Selecting an E/M code based on medical
decision making in 2021. https://practice.asco.org/sites/default/files/drupalfiles/202010/Medical%20Decision%20Making%20NEW.pdf
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Ashley Belli (https://herzing.instructure.com/courses/26424/users/47134)
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I chose the CPT code 99204 on this particular patient. The reason I chose this code is
because I felt the patient’s history and physical revealed the patient to be a moderate level
in complexity. I estimated time spent on the patient to be about 45 minutes. The patient had
a total of four diagnoses, including major depressive disorder, suicidal ideation,
prediabetes, and vitamin b deficiency. Furthermore, the patient’s past medical history,
family history, social history, medications, lab work and allergies were reviewed. The
practitioner also completed a depression screening utilizing SIGEGAPS. A physical exam
was done and a well formulated plan was created. I deemed this patient moderate over
severe because the patient did not have an extensive past medical history. I deemed the
patient a moderate over low because the patient has a total of four diagnoses that need to
be managed, and due to the fact that his mortality rate is elevated secondary to suicidal
and depressive thoughts. It is essential that providers are keeping tabs on time spent on
patient care because in 2021, significant changes were made to evaluation and
management codes, in particular those involving medical decision making. Time spent is
what became the prime driver of which code to bill for in order to be reimbursed. These
revisions simplified code selection. A one-page coding reference tool was created to
simplify the process (Weida & Weida, 2022). Doing so also reduced the amount of required
documentation for reimbursement, which helped to alleviate clerical burden. The overall
effect of this change reduces documentation burden, a change in the configuration of
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Topic: Unit 2 Discussion – New Patient Encounter
notes, and better recognition by Centers for Medicare and Medicaid Services of primary
care and for providers who care for complex patients that require more time for services
(Peters, 2020). Regardless, we must be sure to be submitting the proper codes for two
reasons. One to receive reimbursement and two to avoid fraud.
References
Peters, S. G. (2020). New billing rules for outpatient office visit codes. Chest, 158(1), 298–
302. Retrieved July 18, 2022, from https://doi.org/10.1016/j.chest.2020.01.028
Weida, T., & Weida, J. (2022). Outpatient E/M coding simplified. Family Practice
Management, 29(1).
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Stephanie Lambert (https://herzing.instructure.com/courses/26424/users/41485)
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Ashley,
You made some good points regarding the diagnosis, medical history, family history,
social history, medications, and lab work. I deemed him a moderately difficult patient
and deemed high level of complexity due to life threatening diagnoses, information
reviewed, and risk for complications due to risk factors such as age, diagnosis, and
history. I agree with your reasoning or scoring him as moderate. I felt like with the
amount of information the provider gathered from the patient that he could have easily
spent over 60 minutes with the patient. The American Psychiatry Association provides
many resources to guide providers in CPT billing. CPT codes were first established in
1966 and were adopted by CMS in 1983. These codes served as a basis for reporting
services performed by a physician to Medicare. In 1997, the services included those
provided by nonphysicians (Dewan et al., 2018). These codes are a uniform language
for billing services that increase accuracy and efficiency.
Dewan, N. A., Burd, R. M., Anderson, A. A., Carlson, E. S., Harris, G. G., Jaffe, E.,
Musher, J. S., & Yowell, R. K. (2018). Understanding Coding and Payment for
Psychiatrists’ Services: How We Got Here and Where We’re Going. Focus (American
Psychiatric Publishing), 16(4), 407–414. https://doi.org/10.1176/appi.focus.20180002
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Buffy Bolin (https://herzing.instructure.com/courses/26424/users/45002)
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Monday
The CPT code I would use would be 99205. I used the Medical Decision Making
components (Weida & Weida, 2022). This is a new patient encounter in an office or
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Topic: Unit 2 Discussion – New Patient Encounter
outpatient setting. There is a comprehensive history, including the history of present illness,
past medical history, family history, and social history. A comprehensive exam includes all
body systems minus genital/rectal. Diagnostics include Sig E Caps and PHQ-9
questionnaire. Additional information includes labs and urine dip. Four problems are
identified. The risk of suicide poses a threat to life or bodily function (Weida & Weida,
2022), which would make the medical decision highly complex.
One medication is administered in the office, and two others are prescribed with follow-up
labs and visits ordered. There is also a referral for counseling. The total time for this
encounter would likely be 60 minutes. I felt like more should have been done to address
suicidal ideation. He has a plan and the means to do it. Should hospitalization be
considered for this patient? Is he safe to wait for three to four weeks for the citalopram to
start to act? How long will it take for his referral for counseling to go through and get
scheduled? You are essentially sending a patient who has made preparations for suicide
back into his stressful situation and telling him to wait and see if he feels better in a few
weeks. A verbal contract could be an option. Discussing making arrangements to go
somewhere that he has support, like with a family member or trusted friend, could be
helpful. I think it is irresponsible to do nothing more active than prescribing medication,
refer to counseling and send him home.
References
Weida, T., & Weida, J. (2022). Outpatient E/M Coding Simplified. Family Practice
Management, 29(1), 26. https://prx-herzing.lirn.net/login
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Stephanie Lambert (https://herzing.instructure.com/courses/26424/users/41485)
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1.
the level of history taking achieved – identify the history elements present
With the amount of information that the provider gathered from the patient, they would
have easily spent over sixty minutes with this patient. The patient’s previous history,
present history, and family history were reviewed in detail. His present medical history
includes sleep disturbances, marital issues, suicidal ideations, loss of pleasures, memory
disturbances, and increased depression. He reports a past history of a traumatic injury
causing hearing loss and peripheral vision loss. He also reports missing his first wife who
died. His father died of colon cancer and his mother died of sickness secondary to
influenza during a pandemic when he was young.
2. the type of exam performed – identify the number of systems and bulleted points in
the note
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Topic: Unit 2 Discussion – New Patient Encounter
A head-to-toe physical examination was performed. The systems and parts that were
reviewed during this examination included integument, HEENT, neck, lungs, heart,
abdomen, genitalia/rectum, musculoskeletal system, neurological system, and mental
status.
3.
the level of medical complexity encompassed – include # of points for a)
diagnoses/management options, b) amount/complexity of data reviewed, and c) level of
risk for complications, morbidity, mortality
A) The patient has diagnosis of MDD, prediabetes, Vitamin B deficiency, and SI. He is
considered a high level and scored four points, including diagnoses that are life
threatening.
B) There are multiple test results, such as a CMP, thyroid, prostate specific antigen, folic
acid, vitamin b12, hemoglobin, hematocrit, and urine, that were evaluated. This is scored 1
point. The amount and complexity reviewed for this patient is extensive and scores 3
points for being moderately difficult.
C)The level of risk for complications, morbidity, and mortality score being high due to his
diagnosis, age, and history.
Education was performed regarding his citalopram, safety measures, and nutrition. He was
newly prescribed Citalopram for his diagnosis of major depressive disorder. He has
received a referral for counseling. The provider prepared for the visit, documented
thoroughly, and has evaluated all results. He is a higher risk patient, is a more complex
patient, and is a new patient. I would code him as a 99205.
Current Procedural Terminology provides guidelines to code for reimbursement purposes.
Documentation changes were made in 2019. Some of these changes included
documentation on changes since last visit, team-based documentation, and no need to
document previously recorded information. In 2021, even more changes were made to
simplify documentation and billing. Outpatient visits were reduced from 5 to 3 types. Level
2-4 patients will be billed at an equal rate, and more complex level 5 patients billed at a
higher rate (Gluckman & Vavricek 2019). New codes were introduced and old codes were
removed as a part of the change.
Gluckman, T. J., & Vavricek, J. J. (2019). Streamlining evaluation and management
payment to reduce clinician burden. Circulation: Cardiovascular Quality and Outcomes,
12(4). https://doi.org/10.1161/circoutcomes.118.005426
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Vanessa Bollers (https://herzing.instructure.com/courses/26424/users/47733)
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Topic: Unit 2 Discussion – New Patient Encounter
New Patient Encounter
CPT Code for this Patient
99205-99215
History Elements Present
Patient is a 75-year-old white male who reports that he has been bereaved before and that
he never really recovered fully from the death of his first wife. He reports that he does not
get along well with his current wife and that he is about to lose the home he has lived in for
46 years rendering him sleepless and depressed as he does not find pleasure in various
activities that would initially give him pleasure. Patient reports of a paternal familial history
of colon cancer.
Type of exams performed
Review of System of the Central Nervous System reveals absent history of dizziness and
syncope episodes but reports of neck stiffness and chronic malaise. Patient denies
homicidal thoughts but acknowledges the fact that he has had suicidal thoughts.
Level of Medical Complexity Encompassed
Patient acknowledges that he has been depressed for several years and that his symptoms
are currently associated with suicidal ideations, and this is made worse by the fact that he
has a gun within reach (Thomas, 2021). The patient can therefore benefit from
antidepressants such as Alprazolam that will help improve his mood and subsequent
quality of life (Salari et al., 2020). Patient can also benefit from psychotherapy to help him
learn on how to handle his current situation and how to improve his overall quality of life.
According to Eddington (2017), support programs for the bereaved could go a long way to
give the patient closure over the passing of his first wife. In the event that the patient
refuses medical attention including psychotherapy, his problem could potentially be fatal as
he could end up committing suicide due to the stressors he is currently facing.
References
Eddington, K. M., Burgin, C. J., Silvia, P. J., Fallah, N., Majestic, C., & Kwapil, T. R. (2017).
The effects of psychotherapy for major depressive disorder on daily mood and functioning:
a longitudinal experience sampling study. Cognitive therapy and research, 41(2), 266-277.
https://doi.org/10.1007%2Fs10608-016-9816-7 (https://doi.org/10.1007%2Fs10608-0169816-7)
Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani, A., Rasoulpoor, S., Mohammadi,
M., … & Khaledi-Paveh, B. (2020). Prevalence of stress, anxiety, depression among the
general population during the COVID-19 pandemic: a systematic review and meta-
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analysis. Globalization and Health, 16(1), 1-11. https://doi.org/10.1186/s12992-02000589-w
(https://doi.org/10.1186/s12992-020-00589-w)
Thomas, T. A. (2021). Social Support Experiences of Spousally Bereaved Individuals in a
South African Township Community: The Botho/Ubuntu Perspective. Frontiers in
Psychology, 4024. https://doi.org/10.3389%2Ffpsyg.2021.604987
(https://doi.org/10.3389%2Ffpsyg.2021.604987)
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YAILI MILAGRO ALMAGUER BETANCOURT (https://herzing.instructure.com/courses/26424/users/47119)
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Unit 2B Discussion – New Patient
Encounter
There is a need to take and keep records when a new patient visits a health facility for
various reasons. These records are often taken to facilitate multiple activities in the health
facility, such as billing. Evaluation and Management coding is one of the most effective
ways to enable billing. E/M coding is used to record the physician-patient encounters in
CPT coding that facilitate billing. Evaluation and Management coding is vital since the
codes acquired from the process are used in the healthcare department to account for
various functions within the healthcare setup, such as treatments and all other medication
procedures in the healthcare setting. The insurers use the numeric codes from the E/M to
evaluate the payment carried out within the healthcare setting (Deeken et al., 2018). The
E/M has two guidelines costing the 1995 and 1997 guidelines. These guidelines should not
be combined; thus, physicians must always use one set of guidelines simultaneously. The
contrast between the 1995 and 1997 guidelines is that the former gives a detailed
examination since it addresses 2-7 organ systems. In comparison, the 1997 guideline
indicates that the health practitioner must address over 12 organ systems, one of which
may not be necessary (Hoover et al., 2020). Here are the CPT codes categories:
Evaluation and management services 99201-99499, Medicine services and procedures
90281-99607, Pathology and laboratory procedures 80047-89398, Radiology procedures
70010-79999, Surgery 10021-69990, and Anesthesia 00100-10999.
Physicians are often required to determine the type of the patient, whether
established or new and the encounter setting. In this case study, the most effective coding
would be 99203. Other codes that are primarily used range from 99201 to 99205, with each
code representing the complexity in ascending order. These codes are assigned to new
patients. Another set of codes evident in the Soap note in this case study is code 99201https://herzing.instructure.com/courses/26424/discussion_topics/573742
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99499. These codes are often categorized under evaluation and management services
(Deeken et al., 2018). The outlook of the current Soap note indicates a patient who visited
the health facility complaining of rashes in the body as the CC has been worsening over
the past two months. The patient has also been under medication that tends to relieve the
condition but was further seeking evaluation and management services.
A case study involves comprehensive history taking, which comprises all patient
history elements. The element of the comprehensive history involves constituents such as
social and the family history of the patient, past medical history of the patient, the history of
the current illness, and a complete ROS. It is often required for one to meet all the four
elements to be categorized in a specific group. The above statement is speculated in the
1997 CPT guidelines (Lahey et al., 2022). In the current case study, Soap note, the patient
met all four elements, making the history-taking level comprehensive. It, therefore, shows a
good performance of the systematic examination of the new patient and involves more than
one organ during the general examination. The involvement of more than one organ makes
it falls under a general examination format. The examination of the organ system is made
up of various elements of the physical exam that must be carried out. Comprehensive and
detailed exam levels expanded problem-focused, and the problem-focused forms the
various levels of the exam that should be performed while examining the patient. A
complete general examination was performed in this case, making it fall under the
comprehensive level. In this Soap note, the patient was examined by looking at the
elements for the examination of the selected organ system. The examination was
conducted regarding the 1997 CPT guideline, which qualified the patient under the
complete generalization of the multisystem examination. (Lahey et al., 2022). As a
document in the current Soap note, the physician measured at least three of the seven vital
signs according to the constitutional system exam. The health practitioner also examined
the general appearance of the patient. The results from the general appearance revealed
that the patient was oriented and alert throughout the examination session. The eyes of the
patient were also examined, and both eyes were inspected for the lids and the conjunctiva.
The physician proceeded to examine the pupils, the iris, optic discs, and the posterior
segments. This examination was achieved by conducting the ophthalmoscopy, which
revealed that the posterior elements and the optic disc were in good condition. The
examination further involved the neck, mouth, throat, nose, and ears (Lahey et al., 2022).
Other examination elements undertaken during the examination include assessment of the
hearing ability, nasal mucosa, lips inspection, thyroid examination, and the examination of
the neck oropharynx. The above elements are the most effective elements that physician
often conducts for an effective examination.
Medical complexity is also a vital aspect when assessing a patient. The medical
complexity encompassed during the practice forms the third category. Two diagnoses were
evident in the current Soap note. One of the diagnoses shows a problem that worsened
two months after the patient took the medication. One laboratory test was ordered by the
physician, which was assumed to be the most effective laboratory test that could help
determine the correct diagnosis. Regarding CPT of the 1997 guidelines, the current Soap
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note adhered to all the guidelines, lowering the risks of complications. This phenomenon
led to low complexity decisions. Referring to the lecture notes from the class work, the type
of examination offered by the physician was comprehensive, and the history was also
comprehensive, leading to a low complexity (Lahey et al., 2022). In this case, the patient
qualified 99203 codes by meeting the subjects mentioned above. The patient in this case
study shall be billed according to 99203 codes since the MDM exceeds the billing level
though the patient scored 2/3.
References
Deeken-Draisey, A., Ritchie, A., Yang, G. Y., Quinn, M., Ernst, L. M., Guttormsen, A., … &
Maniar, K. P. (2018). Current procedural terminology coding for surgical pathology: a review
and one academic center’s experience with pathologist-verified coding. Archives of
Pathology & Laboratory Medicine, 142(12), 1524-1532.
Hoover, N. D., Turner, R. B., Sampson, J., Pye, T., & Hotan, T. (2020). Financial
sustainability of an Oregon rural health, primary care, and pharmacist-run comprehensive
medication management program through direct medical billing. Journal of Managed Care
& Specialty Pharmacy, 26(1), 30-34.
Lahey, S. J., Nichols, F. C., Painter, J. R., & Levett, J. M. (2022). The recent decision by the
Centers for Medicare and Medicaid Services to revalue evaluation and management codes
and its negative financial impact on cardiothoracic surgery. The Journal of Thoracic and
Cardiovascular Surgery, 163(3), 1108-1113.
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Based on the H&P and the assessment and diagnosis there are four diagnoses (major
depression, suicidal ideation, prediabetes and vitamin B deficiency).
I will be making a CPT code based on medical management. All of the diagnosis do not
require any additional testing or work up. Therefore, the score would be 12 for number of
diagnosis/management options. For the amount/complexity of data reviewed the provider
would be just reviewing labs which be a score of 1. The risk level would be high as there
are more than 1 undiagnosed new problem with an uncertain prognosis. Risk level would
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Topic: Unit 2 Discussion – New Patient Encounter
be high as there is a new psychiatric illness with a potential threat to self with suicidal
ideation. For this the type of decision making would be high and the CPT code would be
99215.
Coding can the life line for the health care professional as this could be a form of income
especially for private practices. Few physicians have any formal training in CPT coding;
even fewer have pursued certification from the American Academy of Professional Coders
(Holt, Warsy and Wright, 2009). Typically, health care professionals hire staff that are
trained in coding to help with billing. What has to be remembered is that the at the end of
the day the healthcare professional is held responsible for any auditing that might occur,
not the trained coding staff.
Resources:
Jim Holt, MD, Ambreen Warsy, MD, and Paula Wright. (2009), Medical Decision Making:
Guide to Improved CPT Coding. Access:
https://web.archive.org/web/20190303025956id_/http://pdfs.semanticscholar.org/a682
/3341b80738a621417ab3142779fe31384d47.pdf
(https://web.archive.org/web/20190303025956id_/http://pdfs.semanticscholar.org/a682/3341b80
738a621417ab3142779fe31384d47.pdf)
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Sheryl Dixon (https://herzing.instructure.com/courses/26424/users/56651)
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The level of history obtained from the patient leads me to choose CPT code 99205.
There is a complete medical history obtained on this patient. It includes HPI, PMH family
and social history, and ROS that addressed 8 elements. There are diagnostic to include Sig
E Caps and PHQ-9 questionnaire obtained with a score of 19 which represents cut points
for moderately severe MDD. Suicide ideation/ thoughts noted but no attempts voiced
during interview. Comprehensive head to toe physical assessment that addressed 10
elements, deferring genitalia and rectum. However, 4 problems were identified through
diagnostic labs and medication review. The level of medical complexity encompassed in
this visit included the number and complexity of problems addressed received four points
with additional work- up . The amount of complexity of the data reviewed and analyzed
received 1 point which includes the diagnostic labs. The Risk of complication and or
morbidity, mortality states that this patient is at high risk r/t age, comorbidities, and overall
health history.
The CPT terminology is the most widely accepted medical nomenclature used across the
country to report medical, surgical, radiology, laboratory, anesthesiology, genomic
sequencing, evaluation and management (E/M) services under public and private health
insurance programs (Gluckman & Vavricek 2019). All CPT codes are five-digits and can be
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Topic: Unit 2 Discussion – New Patient Encounter
either numeric or alphanumeric, depending on the category. CPT code descriptors are
clinically focused and utilize common standards so that a diverse set of users can have
common understanding across the clinical health care paradigm (Gluckman & Vavricek
2019).
Reference:
Gluckman, T. J., & Vavricek, J. J. (2019). Streamlining evaluation and management
payment to reduce clinician burden. Circulation: Cardiovascular Quality and Outcomes,
12(4). https://doi.org/10.1161/circoutcomes.118.005426
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NU 671 Week 2 D 1 Coding
Dr. Mercer and Classmates,
For the patient in this discussion, I would code the patient as a CPD code 99205. This code
is indicative for new patients only which would be appropriate for this case. CPD code
99205 means high or level 5 office visits and details of the documentation matter to qualify
as “reasonable and necessary.†(Weida & Weida,2022). The estimated time is between 6074 minutes long and this would be appropriate for the 75-year-old gentleman who is in
distress and states “ “I don’t know how much longer I can go on like this. I’ve been down in
the dumps for years and it isn’t getting any better.â€
In my opinion as a PMHNP seeing this patient for the first time, I would like to give him
ample time to discuss how he is feeling in regard to his life which is worrisome. Normally
for an outpatient visit with a patient who is establishing care the code 99204 would be
sufficient as it is a shorter visit in the length of time (under 60 minutes). I would want to
conduct SIGECAPS, PHQ-9 as the practioner did, but I would also conduct the C-SSR
screening to assess for the patient’s risk of suicidal ideation which was eluded to in this
comment on not knowing how much longer he can go on.
There was a comprehensive history taken and a prescription made for the antidepressant
Citalopram. This would be an appropriate choice of medication for an elderly patient but
teaching must be implemented because anti-depressants can take up to 4 weeks for
patients to feel less depressed (McCarrell et al., 2019).
https://herzing.instructure.com/courses/26424/discussion_topics/573742
13/16
7/20/22, 11:21 PM
Topic: Unit 2 Discussion – New Patient Encounter
During this time I would also want to discuss a referral to the mental health navigator as
this patient clearly is in acute need of follow-up and may need to be hospitalized if these
feel exacerbated.
There is also the need to ensure that a family member is aware of how the patient is feeling
and what to look for if the suicidal ideation ramps up. I would also set up a follow-up with
the PMHNP in one month to see if there is any improvement with the medications.
References
Weida, T., & Weida, J. (2022). Outpatient E/M coding simplified. Family Practice
Management, 29(1).
McCarrell JL, Bailey TA, Duncan NA, Covington LP, Clifford KM, Hall RG, Blaszczyk AT
(2019). A review of citalopram dose restrictions in the treatment of neuropsychiatric
disorders in older adults. Ment Health Clin. (4):280-286. doi: 10.9740/mhc.2019.07.280.
PMID: 31293848; PMCID: PMC6607952.
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Sabrina Emukarhowhotite (https://herzing.instructure.com/courses/26424/users/48054)
î«„
Yesterday
Considering the facts, I would use the CPT E&M code for this new patient is 99205.
Mentally ill patients require extensive evaluation, detection of the severity of symptoms,
and in-depth analysis of thought processes, ideologies, and perceptions. The
implementation of tools, interview questions, and evaluation of results is time-consuming.
All these components demand adequate time to invest in a mental health provider. The
total time spent with a new patient should be 60 to 74 minutes which involves evaluation,
management, and a high level of medical decision-making. I personally feel that there
should be more time between the patient and the provider. This patient requires evaluation
of depressive symptoms when he reports that he desires to “give up the fight” which
indicates to me that he possesses thought processes related to suicide as he mentioned
the presence of a 22-caliber rifle at home and shared his feeling to end his life by using that
rifle. The patient also suffers from physical disorders like prediabetes and loss of
appetite.SIGECAPS: reports poor sleep maintenance, and loss of pleasure, he feels as
though he remarried too soon, and he is experiencing fatigue which can contribute to his
mental illness to a certain degree. I know that psychiatric medication can take from six to
eight weeks to be effective, and the patient should be educated on that as well. The HPI is
a part of the interview subjective data from the patient current condition in a narrative form,
https://herzing.instructure.com/courses/26424/discussion_topics/573742
14/16
7/20/22, 11:21 PM
Topic: Unit 2 Discussion – New Patient Encounter
In this case, the patient lost his wife feeling depressed. A head-to-toe assessment of the
body systems is performed.
References
Melnynk, B. M (2020). Reducing health care Cost for mental health hospital with the
evidence-based COPE program for child and adolescent depression and anxiety: A cost
analysis. Journal of Pediatric Health Care,34(2), 117-121
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Nikki Durrant-Campbell (https://herzing.instructure.com/courses/26424/users/33414)
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6:39am
Unit 2 Discussion – New Patient Encounter
Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’
encounter.
You may choose to assign the code based on the anticipated/guestimate amount of time
the provider would spend with the patient in the encounter or you may choose to utilize the
Medical Decision Making (MDM) approach. If you choose the MDM include the following
information in your discussion:
1. the level of history taking achieved – identify the history elements present
The new patient encounters must be more detailed than established encounters. The first
soap note on a new patient requires excellent note-taking to establish proper care for the
patient. The chief of complaint explains the reason for the visit. The history of present
illness (HPI) provides the background for the chief of the complaint. In this case, the patient
describes traumatic events in his life which lead up to this moment. The loss of his first wife
seems to have a profound effect on him. Because he considers her the “love of his life†and
she died forcing him to move on. The present-day wife has also added some stress to the
situation. He explains that he has memory issues that have affected him in the last several
months.
2. the type of exam performed – identify the number of systems and bulleted points in the
note
The type of exam performed is the SIGECAPS. SIGECAPS is a screening tool designed
to diagnose depression. The results of the screening state that this client suffers from poor
sleep, anhedonia, fatigue, suicidal thoughts, and regrets about marrying too quickly (Weida
& Weida, 2022).
https://herzing.instructure.com/courses/26424/discussion_topics/573742
15/16
7/20/22, 11:21 PM
Topic: Unit 2 Discussion – New Patient Encounter
PHQ 9 was another screening tool that is used to assess the severity of depressive
symptoms. His score is 19. A score of 19 is considered moderately severe depression. This
score suggests the client should be treated with medication and therapy (Weida & Weida,
2022).
CBC and CMP were done to rule out underlying health conditions.
The soap note covered 6 body systems. They are the integumentary, digestive, nervous,
respiratory, musculoskeletal, and cardiovascular systems.
3. the level of medical complexity encompassed – include # of points for a)
diagnoses/management options, b) amount/complexity of data reviewed, and c) level of
risk for complications, morbidity, mortality
The CPT code for this patient is 99214. This client has several diagnoses F32.1 major
depression single episode, R45.851 suicidal ideation, R73.03 prediabetes, and E53.9
vitamin B deficiency. This client’s number of diagnoses is 3 for new problems no work up
planned. The amount of data reviewed is 1 point for review or order labs, and 1 point for
discussing tests with the performing provider. The risk of complications is moderate. The
type of decision-making is moderate complexity there is a risk of significant complications
(Dewan et. al., 2018).
References
Deeken-Draisey, A., Ritchie, A., Yang, G. Y., Quinn, M., Ernst, L. M., Guttormsen, A., … &
Maniar, K. P. (2018). Current procedural terminology coding for surgical pathology: a review
and one academic center’s experience with pathologist-verified coding. Archives of
Pathology & Laboratory Medicine, 142(12), 1524-1532.
Dewan, N. A., Burd, R. M., Anderson, A. A., Carlson, E. S., Harris, G. G., Jaffe, E., Musher,
J. S., & Yowell, R. K. (2018). Understanding Coding and Payment for Psychiatrists’
Services: How We Got Here and Where We’re Going. Focus (American Psychiatric
Publishing), 16(4), 407–414.
Peters, S. G. (2020). New billing rules for outpatient office visit codes. Chest, 158(1), 298–
302.
Weida, T., & Weida, J. (2022). Outpatient E/M Coding Simplified. Family Practice
Management, 29(1), 26.
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16/16
Chief Complaint:
“I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t
getting any better.â€
History of Present Illness:
75-year-old white male present to clinic with above complaint. Lost his first, the “love of his life†wife 19
years ago. Remarried 2 years after her death and states he probably married again too soon reporting
his current wife is difficult. He describes an instance, when he was at work, the second wife would not
let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The
second wife also insisted that he no longer visit with his deceased wife’s family telling him ‘when you
married me, you divorced that whole family’. Conversations with his wife about his concerns resulted in
only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he
has lived in for 46 years. He reports that his memory and ability to make simple decisions have been
deteriorating significantly over the last several months. His wife suggested he probably has Alzheimer’s
and should go see his primary care provider about his memory issues. He reports that he engages with
modest exercise daily, eats well but is waking up numerous times at night and is usually “up for good†by
5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all
these circumstances as contributing to his increased depression and his desire to “give up the fightâ€.
PMH:
reports usual childhood illnesses inclusive of measles, mumps and chickenpox
traumatic injury, likely secondary to ‘blast’ effect, sustained during the bombing of Pearl Harbor where
he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was
diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be
secondary to this trauma
Family Hx:
Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an
epidemic (he was 2 years old at that time)
No know family history of depression or other mental illness
Social Hx:
HS graduate, married to HS sweetheart for 27 years then widowed
Current marriage of 17 years
Retired after 25-year banking career
Attends Catholic mass regularly
Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs
Drinks hot tea, reporting coffee causes too much GI distress
Never driven a motor vehicle secondary to poor peripheral vision
ROS:
Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion,
diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms
Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more
depressed during the winter months than other seasons
Reports fatigued most of the time, often feels stiffness in his neck and shoulders
Denies homicidal ideations, hallucinations, paranoia or delusions
Reports suicidal thoughts, has a 22-caliber rifle at home and has considered using to end his life
SIGECAPS:
Reports – poor sleep maintenance, loss of pleasure, he feels as though he remarried too soon, he is
experiencing fatigue, he is experiencing memory disturbances, eating well, no problems maintaining
exercise regimen, is having suicidal ideations
Medications:
No routine medications
Allergies:
None
Physical Examination:
Constitutional – BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt 174 lbs, BMI 24
Integument – skin, hair and nails unremarkable
HEENT – PERRLA, EOMs intact, nares patent without discharge noted, TMs gray and shiny bilateral,
numerous silver amalgams noted
Neck – supple without adenopathy, no thyromegaly
Lungs – CTA
Heart – RRR without murmur/gallop
Abdomen – soft, non-distended, active bowel sounds, non-tender, no organomegaly
Genitalia/Rectum – deferred
Musculoskeletal – no gross abnormalities or major limitations of ROM noted
Neurologic – CNs II-XII intact, finger-to-nose test negative, DTRs 2+ and equal bilateral, sensory capacity
intact upper and lower extremities intact bilateral
Mental status – PHQ 9 score is 19
Diagnostics – Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L, HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL,
fasting Glu 106 mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42 IU/L, GGT 38 IU/L, Alb 4.4 g/dL,
TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9 ng/mL, Hgb 14.3 g/dL, HCT 41.4 %
Urine dipstick – 5.8 pH, SG 1.016, all other parameters negative
Assessment:
1.
2.
3.
4.
F32.1 Major depressive disorder, single episode, moderate
R45.851 Suicidal ideations/thoughts
R73.03 Prediabetes
E53.9 Vitamin B deficiency
Plan:
1. Major depressive disorder
a. Diagnostic – none
b. Therapeutic – citalopram 20mg take 1 by mouth daily dispense #30 with 2 refills
c. Educational – effects of citalopram may not be fully evident for up to 3 or 4 weeks; if
you note fatigue exacerbated from the citalopram take it at bedtime; RTC in 1 month for
follow up
d. Consultation/Collaboration – none
2. Suicidal ideations/thoughts
a. Diagnostic – none
b. Therapeutic – same as diagnosis #1
c. Educational – same as diagnosis #1; educate on the potential negative impact of his
current intake of beer – educate on how to safely reduce this consumption and to avoid
abrupt cessation; educate on need to remove the 22-caliber rifle from his home; provide
information on suicide hot lines
d. Consultation/Collaboration – referral for counseling
3. Prediabetes
a. Diagnostic – none
b. Therapeutic – none
c. Educational – nutrition education aimed at making dietary lifestyle choices of low
glycemic index foods (
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