Reviewing encounter for recent TOC(established patient) visit with what could have been a moderate to high level MDM. However patient has Medicaid coverage so 99495 and 99496 is not usable even if MDM was moderate Diagnosis are of a higher complexity but confused by lack of MDM
I’m wondering if anyone would help advise on most appropriate E/M
Every aspect of HPI and history and Exam is detailed/ to comprehensive, no coordination of care was documented I’m just not certain what is most appropriate given the complexity of dx verses MDM
Assessment:
1. Body mass index (BMI) of 19 or less in adult – Z68.1 (Primary)
2. Acute ischemic right MCA stroke – I63.511, Appreciate recent hospitalization Continue rehabilitation
3. Hemiparesis of left nondominant side due to non-cerebrovascular etiology – G81.94
4. Other symptoms and signs involving cognitive functions and awareness – R41.89
5. Hypertension – I10, Patient is at goad: <140/90 per JNC 8 Guidelines – Blood pressure was in range. Taking medications as prescribed. No medication side effects noted. Continue monitoring blood pressure at home/record flow-sheet, bring for review.
6. Wolff-Parkinson-White syndrome – I45.6
7. History of coronary rotational ablation – Z98.890
8. Status post placement of implantable loop recorder – Z95.818, implanted on 2/23/18
9. Anxiety – F41.9

Plan:

1. Others
Notes: Reviewed and encouraged compliance with current treatment plan
Notify doctor if any changes or concerns
Warrents close follow-up.

Would really appreciate any help or advice
Thank you Cheri