Patient opens eyes to her name only. She does not answer any questions. Nurses report that she has become increasingly difficult to arouse over the past three weeks. She has been having trouble swallowing food and has been pouching food in her cheek. There have been no reported incidents of choking.
Nurses report two or three episodes of the patient briefly staring off into space.
In our vignette, several HPI and PFSH elements are documented, but no review of systems occurred, so the history is problem focused. The exam covered eight systems, which makes it comprehensive. Despite a high score for diagnosis and management options, the limited amount and complexity of data to be reviewed and the moderate risk associated with prescription drugs and physiologic testing amount to decision making of moderate complexity. Because only two of the three key components must be met to code a subsequent nursing facility service and because the exam is comprehensive and the decision making is of moderate complexity, the appropriate code is 99313. We'll discuss these codes in the next Coding Challenge installment.