Rene Posted Tue 09th of June, 2015 12:03:57 PM
I was wondering if you have any suggestions for questions our providers could ask on a new patient coming in for an elevated PSA... I'm having a hard time getting them above a 99202 because of the HPI
SuperCoder Answered Tue 09th of June, 2015 17:23:35 PM
Thanks for your question. A level two new patient visit requires an expanded problem focused history and exam and a low medical decision making. Assuming that your exam and medical decision making are at a higher level and you have met a higher level of past medical, family, and social history and your review of systems is above expanded problem focused, your provider should document any symptoms that the patient is having. The duration, timing of the symptoms,and etc. will aid in allowing you to count more elements in the HPI and obtaining a higher level. For example, "The patient presents with a two month history of weak urinary stream. The patient indicated that he frequently urinates, sometimes every 30 minutes but still feels like his bladder is not empty. The patient also has tried to reduce water intake at night with no relief in symptoms." Hope this helps.