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

Title: Correct Billing Code Determination for Patient SOAP Notes

Introduction:

In healthcare settings, documenting patient encounters is crucial for accurate record-keeping and billing purposes. The SOAP (Subjective, Objective, Assessment, and Plan) note format is widely used by healthcare providers, including Nurse Practitioners (NPs), to document patient encounters. Additionally, appropriately assigning the correct billing code based on the complexity of patient encounters is essential to ensure accurate reimbursement. This assignment aims to identify the appropriate billing code for three patient encounters based on the provided SOAP notes and supporting resources.

Determining the Appropriate Billing Code:

To determine the appropriate billing code, we will analyze each SOAP note individually, assessing the complexity of the patient encounter according to the Evaluation and Management (E&M) coding guidelines. These guidelines provide detailed criteria for each level of service (e.g., 99211, 99212, 99213, etc.) based on the documentation of history, examination, and medical decision-making.

SOAP Note 1:

Subjective:
A 30-year-old female presents with a complaint of sore throat and fever for two days. Denies any cough or difficulty swallowing.

Objective:
Vital signs: Temp 101°F, pulse 78 bpm, BP 120/70 mmHg, respiratory rate 16 breaths per minute. Neck examination reveals erythema and tonsillar exudates.

Assessment:
Diagnosis: Pharyngitis
Plan:
– Prescribed antibiotics
– Educated patient regarding proper hygiene practices to prevent the spread of infection
– Advised to follow up if symptoms worsen or persist

Rationale:
Based on the provided SOAP note, the patient presents with a straightforward case of pharyngitis and is prescribed antibiotics. The examination indicates the presence of erythema and tonsillar exudates. According to the E&M coding guidelines, a straightforward problem that requires straightforward decision-making meets the criteria for a 99213 level of service. This code is appropriate for an established patient encounter, as the patient is not new to the provider.

SOAP Note 2:

Subjective:
A 55-year-old male presents with a complaint of chest pain and shortness of breath. The pain is described as a squeezing sensation and is radiating to the left arm.

Objective:
Vital signs: Temp 98.6°F, pulse 102 bpm, BP 150/90 mmHg, respiratory rate 22 breaths per minute. Lung examination reveals decreased breath sounds on the left side.

Assessment:
Diagnosis: Possible myocardial infarction
Plan:
– Performed an EKG
– Administered aspirin and nitroglycerin
– Initiated a transfer to the nearest emergency department for further evaluation and management

Rationale:
In this case, the SOAP note presents a complicated patient encounter with a potential diagnosis of myocardial infarction. The patient experiences classic symptoms of chest pain radiating to the left arm and exhibits abnormal vital signs and lung examination findings. According to the E&M coding guidelines, a moderate level of complexity exists due to the complexity of medical decision-making involved. Therefore, the appropriate billing code would be 99214 for this established patient encounter.

SOAP Note 3:

Subjective:
A 65-year-old female presents for a routine follow-up visit for her hypertension and diabetes management. Denies any new symptoms or concerns.

Objective:
Vital signs: Temp 98°F, pulse 70 bpm, BP 130/80 mmHg, respiratory rate 18 breaths per minute. Physical examination reveals no abnormalities.

Assessment:
Diagnosis: Hypertension and diabetes mellitus
Plan:
– Continued existing medication regimen
– Educated patient regarding lifestyle modifications for better disease control
– Ordered lab tests for glycated hemoglobin and lipid panel

Rationale:
The third SOAP note describes a straightforward follow-up visit for the management of hypertension and diabetes mellitus. The patient denies any new symptoms or concerns, and the physical examination reveals no abnormalities. According to the E&M coding guidelines, a straightforward problem with no significant changes would meet the criteria for a 99212 level of service. This code is appropriate for an established patient encounter.

Conclusion:

Through systematic evaluation of the provided SOAP notes and utilization of the E&M coding guidelines, the appropriate billing codes for the three patient encounters can be determined. Accurately assigning the appropriate billing code ensures proper reimbursement while reflecting the complexity of patient encounters.