Case
-T1-2A INITIAL HOSPITAL CARE
LOCATION: Inpatient, Hospital
PATIENT: Dorothy Lien
ATTENDING PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Pelvic pain and pain with periods
HISTORY: This lady is a 34-year-old married white female, gravida 2, para (to bring forth)
2. Her LMP (last menstrual period) was April 30, and she received an injection of Depo-Provera at 200 mg (milligram) IM (intramuscular) on May 2. The patient has a long-standing history of endometriosis dating back to June 10 years ago when she had bilateral ovarian cystectomies for endometriosis in her hometown. She was then treated with Danazol for 6 months. I saw her initially back 3 years ago for secondary infertility. She had a laparoscopy with lysis of adhesions the following year, at which time the right ovary was mildly adherent to the pelvic sidewall but was broken up somewhat with dissection, and she had some small bowel adherent to the left ovary. She was then treated on multiple cycles of Klonopin citrate because of luteal phase deficiency but failed to conceive. Last year, she underwent repeat laparoscopy with exploratory laparotomy and pelvic adhesiolysis, having had bowel and pelvic adhesions, and she had resection of several areas of endometriosis. At that point, the patient continued to try and get pregnant but was having more problems; therefore, she was treated with oral contraceptives and nonsteroidal anti-inflammatory drugs. The patient did spontaneously conceive and delivered her second child on August 20. She was not having much success in alleviating her symptoms of dysmenorrhea and dyspareunia; therefore, she was begun on continuous oral contraceptives in the form of Demulen 1/50 back in January. This did result in the expected amenorrhea, and her symptoms were initially controlled fairly well. She then started having more in the way of cramping and pain; however, dyspareunia had improved. At this point, she is being brought in for definitive surgery because of persistent pelvic pain and cramping.
CURRENT MEDICATIONS: None
ALLERGIES: None
REVIEW OF SYSTEMS: She has occasional lower abdominal cramping, but this has improved somewhat since her injection of Depo-Provera. She has no URI (upper respiratory infection) symptoms or cough. No GI (gastrointestinal) or GU (genitourinary) symptoms. No vaginal discharge.
FAMILY HISTORY: Her dad has maturity onset diabetes, coronary artery disease, and hypertension, but he is living. Her mom is in good health. She had two maternal aunts with breast cancer, and there are other types of cancer in her mother's siblings, the specifics of which are unknown.
SOCIAL HISTORY: The patient is a teacher at the local elementary school in her
hometown. Habits: Occasional alcohol. Very rarely does she smoke a cigarette.
PAST SURGICAL HISTORY:
1. Laparoscopy, exploratory laparotomy with adhesiolysis.
2. Ovarian cystectomy and appendectomy.
3. Diagnostic laparoscopy.
PHYSICAL EXAMINATION: Weight is 162 pounds. Blood pressure is 100/60. Pulse, 60. HEENT (head, ears, eyes, nose, throat) are unremarkable. Neck has no masses. Lungs are clear to auscultation. Heart has a regular rhythm without audible murmurs or gallops. Breasts are negative. Abdomen is soft and shows a laparoscopy scar and Pfannenstiel scar. Vulva and vagina are normal. Cervix is parous. Uterus is anterior and normal size. Adnexa reveal tenderness on the left but not on the right. On rectovaginal examination, there is some extreme nodularity on the left side of the cul-de-sac. Extremities show no phlebitis.
LABORATORY STUDIES: Preop laboratory work shows the urinalysis to be normal.
White count is 5440. Hemoglobin is 13.6 g (gram).
PREOPERATIVE DIAGNOSIS: Endometriosis with chronic dysmenorrhea and pelvic pain.
OPERATIVE PLAN: Total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient will receive a mechanical and antibiotic bowel prep, and she will also have ureteral catheters placed preoperatively by Dr. Avila. The patient understands the potential complications, infections, bleeding, bowel, bladder, and ureteral injury. Potential complications of blood clot formation and pulmonary emboli are also discussed with the patient. She understands the necessity of the operation, its intended outcome and risks, and agrees to proceed as planned.
T1-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 99221-57 (Evaluation and Management, Hospital)
ICD-10-CM DX: N80.9 (Endometriosis)
Explanation: The HPI included 4 elements: location (pelvis), duration (long-standing history, back to June 10 years ago), modifying factors (contraceptives improved the condition), and associated signs and symptoms (cramping) for a level 4 or comprehensive HPI. The ROS included 3 elements: respiratory (URI), gastrointestinal (no GI symptoms), and genitourinary (no GU symptoms) for a level 3 or detailed ROS. The PFSH contained all 3 elements for a level 4 or comprehensive PFSH. A comprehensive HPI, detailed ROS, and comprehensive PFSH place this case in level 3 or a detailed history.
The examination included 3 constitutional elements: blood pressure, weight, and pulse for 1
OS. There were 4 BAs reviewed: head (H in HEENT, unremarkable), neck (no masses), chest (breast and adnexa), and abdomen (soft). There were 7 OSs reviewed: ophthalmologic (E in HEENT), otolaryngologic (ENT in HEENT, unremarkable), cardiovascular (heart regular, no phlebitis), respiratory (lungs clear), integumentary (scar), gastrointestinal (recto in rectovaginal), and genitourinary (vaginal in rectovaginal, vulva, cervix, and uterus). There was a total of 12 BAs/OSs which would usually make this is a level 4 or comprehensive examination; however, BAs are not counted for the comprehensive examination. Recounting there was 1 OS for the constitutional elements and 7 OSs noted during the examination. This examination still qualifies as a comprehensive examination.
The MDM included a limited number of diagnoses/management options, a minimal amount of data to review (labs), and a moderate risk to the patient (elective surgery is moderate risk). This is a level 2 or low MDM.
The key components consist of a detailed history, comprehensive exam, and low MDM. This supports 99221.
Note that the choice of the correct code depends on all three of the key components to assign an Initial Hospital Care code. 99221 requires a detailed or comprehensive history, a detailed or comprehensive exam, and straightforward or low MDM. 99222 requires a comprehensive history and comprehensive examination level and MDM of a moderate level. While the exam is comprehensive and meets the requirements of the higher levels of codes, the history and MDM support the lower level; therefore 99221 is the correct code.
Modifier -57 is added to indicate a decision for surgery was made during the E/M service.
The diagnosis is endometriosis as stated in the Preoperative Diagnosis section of the report. Dysmenorrhea and pelvic pain are not coded because they are symptoms of endometriosis, which is the more definitive diagnosis.

Case -T1-2A INITIAL HOSPITAL CARE