In this assignment, you are provided with three patient SOAP notes from an encounter with an NP. Using the Required Readings and Required Resources, including the and identify the appropriate code (i.e. 99211, 99212, 99213 etc.) that should have been billed for the visit. In addition, provide detailed rationale on how you came to this decision. Please use the ASSIGNMENT TEMPLATE ATTACHED TO COMPLETE ASSIGNEMENT.). CODING PDF (please copy and paste the link on the search bar) https://lmscontent.embanet.com/RC/MSN/NU668/Docs/E_and_M_Chart_Requirements_Coding.pdf https://lmscontent.embanet.com/RC/MSN/NU668/Docs/Week16_Eand_M_Coding.pdf
SOAP Note 1:
Patient Name: John Doe
Age: 45
Chief Complaint: Cough and congestion
Subjective: John Doe presents with a chief complaint of cough and congestion for the past five days. He reports that the symptoms initially started as a mild sore throat and have since progressed. He denies any fevers, chills, or night sweats. He reports that over-the-counter cough suppressants have provided minimal relief. He denies any shortness of breath or wheezing. He reports no known allergies or medication use. Past medical history is significant for seasonal allergies.
Objective: Vital signs are within normal limits. Physical examination reveals nasal congestion, postnasal drip, and clear rhinorrhea. Lungs are clear to auscultation bilaterally. No wheezes or rhonchi are present. No other abnormalities are noted on examination.
Assessment: Acute upper respiratory infection
Plan: Recommended symptomatic treatment, including rest, fluids, and over-the-counter saline nasal spray for nasal congestion. Advised to follow up if symptoms worsen or persist beyond seven days.
SOAP Note 2:
Patient Name: Jane Smith
Age: 30
Chief Complaint: Knee pain
Subjective: Jane Smith presents with a chief complaint of right knee pain for the past three days. She reports that the pain started after she twisted her knee while running. She rates the pain as a 6/10 and reports that it is worse with movement. She denies any swelling or redness in the area. She reports no known allergies or medication use. Past medical history is unremarkable.
Objective: Vital signs are within normal limits. Physical examination reveals mild tenderness over the medial aspect of the right knee joint. No swelling or redness is noted. Range of motion is slightly limited due to pain. No other abnormalities are noted on examination.
Assessment: Acute knee strain
Plan: Recommended rest, ice application, elevation, and over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. Advised to follow up if pain persists beyond two weeks or worsens.
SOAP Note 3:
Patient Name: Sarah Johnson
Age: 35
Chief Complaint: Depressed mood
Subjective: Sarah Johnson presents with a chief complaint of depressed mood for the past month. She reports feeling sad, hopeless, and irritable most of the time. She denies any suicidal ideation. She reports difficulty sleeping and a loss of interest in activities she used to enjoy. She denies any recent life stressors or significant changes in her life. She reports no known allergies or medication use. Past medical history is significant for anxiety disorder.
Objective: Vital signs are within normal limits. Physical examination reveals no specific abnormalities.
Assessment: Major depressive disorder
Plan: Recommended referral to a mental health specialist for further evaluation and consideration of pharmacological therapy or psychotherapy. Advised to follow up in two weeks.
Based on the provided SOAP notes, let us determine the appropriate code to be billed for each encounter. In order to do so, we will refer to the E&M Coding Guidelines and Requirements document, as well as the Week 16 E&M Coding presentation.
For SOAP Note 1, the patient presented with a cough and congestion. The examination findings were relatively normal with only nasal congestion and clear rhinorrhea observed. The diagnosis made was an acute upper respiratory infection, and the plan involved symptomatic treatment and follow-up if symptoms worsen or persist. Based on these factors, the appropriate code to bill for this encounter would be 99213. The key components met for this code are the history (chief complaint and past medical history), examination (physical exam findings), and medical decision-making (diagnosis and treatment plan) criteria.
In SOAP Note 2, the patient complained of knee pain after a recent injury. The examination revealed tenderness and limited range of motion. The diagnosis made was an acute knee strain, and the plan included rest, ice, elevation, and pain medication, with a follow-up if the pain persists or worsens. Considering these aspects, the appropriate code to bill for this encounter would be 99213. The key components met are the history (chief complaint and past medical history), examination (physical exam findings), and medical decision-making (diagnosis and treatment plan) criteria.
Finally, in SOAP Note 3, the patient presented with a depressed mood. The examination did not reveal any specific abnormalities. The assessment made was major depressive disorder, and the plan involved referral to a mental health specialist for further evaluation and treatment options, with a follow-up in two weeks. Based on these factors, the appropriate code to bill for this encounter would be 99213. The key components met are the history (chief complaint and past medical history), examination (normal findings), and medical decision-making (diagnosis and treatment plan) criteria.
In conclusion, based on the E&M Coding Guidelines and the details provided in the SOAP notes, the appropriate code to bill for each encounter would be 99213. This code reflects a level of service that includes a detailed history, examination, and medical decision-making. The rationale for this decision is that the complexity of the cases presented in the SOAP notes corresponds to the criteria set forth for a 99213 code.