Coding Level

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I recently started a new job in a walk in clinic after many years working in an orthopedic practice. I’m trying to get familiar with the new system and coding for the visits. They use SOAP notes verses transcribed notes. A girl in the office came to me today and said she’s upcoding a workers compensation claim because she felt the PA spent alot of time with the patient. I told her if you are going to bill per the time he needs to have the amount of time spent with the patient in the note. Which he didn’t Can you help me and tell me what level you believe this service should be ….. All vitals were taken and documented… then what shows as the note is: SUBJECTIVE: Here with c/o knee pain x 2 days. He is a dancer and workins in a play. He injured himself on set when
twisting knee. Pain worse with bending. Denies known acute trauma. Denies instability, locking, or clicking. Pain level moderate.
No swelling. OBJECTIVE: GEN: NAD.. LUNGS: clear, no wheezes, rales, rhonchi.. CV: RRR, no murmurs, rubs, gallops. Knee with no tenderness to palpation, no effusion. Full range of motion. Collateral ligaments intact, negative anterior/posterior drawer.. Negative McMurrays, negative Steinman’s,. No patella apprehension..
ASSESSMENT: Knee Strain PLAN: RICE. Plain films of knee ordered
Refused knee brace
I appreciate your help and opinion.

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