P Posted Wed 20th of March, 2019 18:58:46 PM
Reason for visit: Right Knee - H&P
History of Present Illness
A 52 year old male presents for follow-up of right knee meniscus tear. Overall, symptoms have been somewhat persistent. There is pain with maximal flexion. He does have mechanical symptoms as well as pain at times. Patient has been resting his right knee. He has been having difficulty playing soccer due to pain and swelling the following day after rigorous activity. The patient denies any numbness and tingling. He has a history of right knee arthroscopy with partial lateral menisectomy done April 2010. I have also seen the patient for right shoulder pain. He continues to have shoulder symptoms. When I last saw him I recommended that he obtain an MRI of his cervical spine as well. At that time I felt that at least a portion of his right shoulder symptoms were coming from his cervical spine.
MRI of right knee without contrast done 2/5/19 shows horizontal tear at the junction of the posterior horn and body of the medial meniscus. The tear involves the tibial surface of the meniscus. Small Baker's cyst.
4 views of the right knee including a standing AP and PA view as well as a lateral and sunrise view were done 1/21/19. 3 comparison views of the left knee including a standing AP and PA view as well as a sunrise view were done 1/21/19. Findings include no signs of significant fracture. Normal bony alignment. Well-maintained joint spaces.
EMG of right upper extremity done 7/18/17 shows mild chronic denervation changes in the right triceps suggestive of a possible old/chronic mild right C7 radiculopathy. No acute denervation changes are seen. No electro-diagnostic evidence of carpal tunnel syndrome, ulnar nerve entrapment, or radiculopathy sensory neuropathy on the right.
MRI of cervical spine without contrast done 2/27/19 shows at C3-4, there is a 2mm central disc bulge At (5-6, there is a 3mm disc bulge with bilateral disc/osteophyte complexes causing severe narrowing of both neural foramina. At 05-7, there is a 1.5mm central disc bulge. No myelopathy. The central canal is slightly tight behind C5-6.
General: The patient appears healthy and their stated age.
Psych: Alert and oriented x3 in no acute distress.
Neuro: Extremity is neurologically intact with intact sensation and motor distally.
Head: Normocephalic and atraumatic.
Eyes: Anicteric pupils which are symmetric and extraocular movements are intact.
Lungs: No audible wheezing. Symmetric expansion with inspiration.
Skin: Intact without any rashes or significant abrasions.
Vascular: The extremity is vascularly intact distally.
Lymphatics: No evidence of lymphadenopathy.
Right knee: Hips have full passive symmetrical range of motion without irritability. Range of motion is 0-120. Minimal effusion. No facet tenderness. Minimal crepitus. Normal neurovascular exam. There is a positive McMurray for pain medially as well as medial joint line tenderness. No lateral joint line tenderness.
Examination of his cervical spine shows mild to moderate decreased lateral rotation and bending to each side with a complaint of a feeling of stiffness. Hoffmann sign was negative bilaterally. Neurological exam is upper extremities was otherwise normal on today's exam.
Right knee medial meniscal tear Right knee effusion History of right knee arthroscopy done April 2010 Cervical stenosis with severe neural foraminal stenosis at C5-6 bilaterally
I had a long discussion with the patient today concerning the diagnosis as well as the diagnostic studies and treatment options including conservative versus surgical. Because of persistent symptoms, the patient has decided to proceed forward with operative intervention. The planned procedure as well as needed for postoperative rehabilitation and expected outcome was discussed with the patient. All questions were answered.
A history and physical for their planned right knee arthroscopy was done today. The planned procedure as well as the risks including but not limited to bleeding, infection, scars, continued pain secondary to progressive arthritis as well as the medical risks including the risk of anesthesia have all been discussed with the patient. The patient understands these risks and wishes to proceed forward with surgery.
As far as his neck and shoulder is concerned I did go over his MRI findings with him of his cervical spine which was done 2/2]/2019. I explained to him the fact that he does have significant neural foraminal stenosis at C5-6 both on the left and right side. I discussed with him the fact that some of his right shoulder symptoms certainly could be coming from his neck. I've recommended a course of physical therapy for a cervical stabilization program. If his symptoms increase he may be a candidate for epidural steroid injections or other treatment for his neck.
Our doctor wants to bill 99215 for the right knee, 99214-25 for the patient's neck and shoulder. I advise him that 2 E/M codes are not allowed for the same patient billing with the same tax ID. He wants to see Blue Cross' policy about this. I'm unable find it online with Blue Cross PPO, California. Please help me to find written policy with Anthem, California. Thank you.
SuperCoder Answered Fri 22nd of March, 2019 08:08:40 AM
Thanks for your question.
As per your advice it is correct that two E/M cannot be billed together on same patient billing or tax ID.
Please find below link from BCBS Anthem on Page 2 in Para b, it suggests following the CMS guideline on using E/M code.
We were unable to find the guidelines for BC PPO, California.
Hope this helps.