Bradley L. Laymon, PA-C, CPC, CEMC
PRESENTATION
A 47-year-old established male patient presented after 2 days of COVID-like symptoms (fever >100.5°F, cough, headache). Symptoms were mild and constant. He denied chest pain, shortness of breath, abdominal pain, rash, dizziness, and nausea/vomiting/diarrhea. He reported trying to alleviate the symptoms with acetaminophen and guaifenesin, with minimal relief. He has no known allergies
The patient, who had never tested positive for COVID-19, acknowledged recent exposure to a colleague who did. At the time of presentation it had been less than 2 weeks since he completed his COVID-19 vaccination.
Providers wore PPE during the encounter.
Current Outpatient Medications
- Hydrochlorothiazide 25 mg tablet daily
- Bupropion 200 MG 12-hour tablet, twice daily
- Zolpidem tartrate 10 mg tablet, as needed at bedtime
Current Facility-Administered Medications
- Nirmatrelvir-ritonavir 300 mg-100 mg tablet pack
Physical Exam
- Blood pressure 153/109
- Pulse 94
- Temperature 97.5°F (36.4 °C)
- Respiration 16
- SpO2 98%
- Height 5′ 9”, weight 268 pounds, BMI 39.6
- General appearance: Alert, appears stated age, cooperative and in no distress
- Head: Normocephalic, without obvious abnormality, atraumatic
- Eyes: Conjunctivae/corneas clear; PERRLA; no discharge
- Lungs: Clear to auscultation bilaterally. No rales, rhonchi, or wheezing
- Heart: Regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop
- Skin: Color, texture, turgor normal. No rashes or lesions
Assessment
- COVID-19 virus infection
- Hypertension
- Obesity
The Plan
The patient was instructed to follow up with his primary care provider regarding his elevated blood pressure, and to continue hydrochlorothiazide and other medications at the prescribed doses and to check his BP daily. He was instructed not to take over-the-counter decongestants.
Given that his BMI was 39, we discussed diet/exercise/reduced caloric intake to lose weight and body fat. He was advised to discuss this with his PCP, as well.
Encounter Summary
- Point-of-care COVID-19 nucleic acid test positive for COVID-19. Instructed to following CDC guidelines for quarantine
- Initiated nirmatrelvir-ritonavir after discussing risks/benefits
- OTC acetaminophen PRN. Advised to follow up with PCP and to go to the ED if worse
CODING CONSIDERATIONS
Previsit planning was completed via Snapshot and review of chart. I reviewed the patient instructions on the after-visit summary; the patient and family verbalized that they understood what their problem is, what they need to do about it, and why it is important that they do it.
The patient and family voiced understanding of all medications. No barriers to adherence were noted. Patient was taking and tolerating all medications. AVS was given to patient/MyChart.
Number and Complexity of Problems Addressed
Patient complains of fever, headache, and cough but has a history of obesity and HTN. This would meet the criteria for, “2 or more stable chronic illnesses” which would be a moderate problems addressed (level 4).
Amount and/or Complexity of Data to be Reviewed and Analyzed
One lab test was ordered (POCT COVID). This would be minimal complexity of data (level 2).
Risk of Complications and/or Morbidity or Mortality of Patient Management
Prescription drug management (nirmatrelvir-ritonavir) was used to treat COVID. Risk would be moderate due to prescription drug management (level 4).
Two of the three elements of medical decision-making need to be met when choosing your level of service. We successfully met level 4 criteria in the Data and Risk categories, so this is a 99204.
CONCLUSION
This patient had a history of obesity and hypertension, which could significantly adversely affect the patient’s prognosis. If you use comorbidities in the diagnosis, a treatment plan must be documented to use, “2 or more stable chronic illnesses.” If the provider did not add these comorbidities as diagnoses, the LOS would have been level 3 (1 acute, uncomplicated illness or injury, minimal data, and prescription drug management).
Bradley L. Laymon, PA-C, CPC, CEMC is a practicing PA with Novant Health GoHealth Urgent Care. He is also a Certified Professional Coder (CPC) and Certified Evaluation and Management Coder (CEMC).
