Unilateral VS Bilateral Conjunctivitis

And Dr. Cockrell, for our next case we want to differentiate unilateral vs. bilateral conjunctivitis. What happens when you see a patient that presents either one way or at the follow-up visit it’s now progressed to a bilateral. So, if you’ll kind of walk us through that and utilizing those elements please. 

Great, I would love to do that Maritza. And keep in mind that all the way through this, just about all these statements can be debated one way or another. So, if you tweak them maybe one level based on your decision making and I tweak another one, just make sure that your documentation supports that. Because you know there are people who consider maybe a bacterial conjunctivitis or a viral conjunctivitis, a bilateral one to be a minimal issue, straightforward, self-limiting. I don't necessarily agree that they are self-limiting. They get better, but they truly return to the baseline health prior to the infection. I've seen many of them in my career that were left with some kind of residual hyperemia, even though the majority of their subjective complaints have resolved. So, I’m not sure I believe that their self-limited back to the baseline without intervention of some kind. You may disagree with that and I certainly respect your assessment. But let’s take a look and then also I think just the difference between a patient that presents with a bilateral conjunctivitis as opposed to a unilateral conjunctivitis or viral conjunctivitis is a big distinction and a bilateral conjunctivitis whether it’s allergic, whether it’s viral, I'm probably going to put that into under the level of complexity of problem, I’m going to reverse engineer for my diagnosis and I’m probably going to have one acute uncomplicated illness. So, a level 3 or low as far as the number and complexity. That’s bilateral. 

Then we go over to amount and complexity of data. I’m probably going to do a couple of tests, maybe I’m going to do anterior segment photography. I’m certainly going to stain the patient and look at the slit lamp. I may have reviewed prior notes, if somebody else has referred the patient to me, but if they presented to me, I’m not going to have that. I may have, I may be able to meet the ordering of unique tests. I’m not real concerned about it in my particular case. If it’s a pediatric or somehow not cognitively aware patient, we might be able to meet category two. But we may be minimal or none, so we’re back to a level two. But then we’re going to drop, in my particular case, I’m going to treat that patient. I'm probably not just going to let it be self-limited. So, I’m going to add prescription drug management and probably going to drop me into a level four immediately and it’s going to throw out my amount and or complexity of data element and my next lowest element would be low or level three. So, I’m probably going to bill that particular patient as a 99213. And had that patient presented with a unilateral red eye, to me, that requires a little bit different or maybe even dramatically different level of differential diagnosis, just by being unilateral. So, was it trauma, was it herpes simplex virus, something that now I'm going to look and say one undiagnosed new problem with uncertain prognosis. I’m going to be in the moderate category or level four immediately. There’s a potential, depending on the history and review of systems and history of present illness that maybe I'd end up with a low number of problems and complexity addressed or one acute uncomplicated illness or surgery. But I’m certainly not going to start with that in my mind. And then under amount and complexity of data reviewed, I’m definitely, I’m probably going to take anterior segment photographs. I’m going to order that and I’m going to do that test. So, depending on whether we separate the act of ordering from the act of performing or not, we may be able to meet one of the bullet points in that category. Of course, it’s patient referred and we are reviewing external notes from another source we’re going to meet that the patient presents in our office, probably not. We may require that however that the independent historian patient is pediatric or somehow cognitively compromised. We probably are not going to have an independent interpretation test performed by another physician, but we certainly may discuss that there’s a possibility of problems that may need further treatment or the possibility of a viral keratitis, that’s high risk. We certainly may meet that. We only have to meet one out of those three categories anyway to be in a moderate level. We could probably meet two of them depending on the history and review of systems. And then, we’re going to be in to prescription drug management with no problem. So certainly the initial presentation of a unilateral conjunctivitis is easily qualified for a level four, maybe even the follow up will qualify for a level four. It very well may not be stable and it may not be back to our goal, so we’ve got progression involved or side effects of treatment. We prescribed maybe an antiviral that has significant toxicity. 

Thank you for that. I think it’s important to evaluate each case so you’re not necessarily approaching each case the same way, that you also have to take into consideration the patient in front of you and some other additional elements into that. So, thank you for that.

Really taking a look at the patient in front of you and assessing what did we do, what did the problem really present, what was the context of the problem, was it stable, was it not stable, was it progressing, is it acute, are there multiple problems that I’m addressing. Just taking a look to run through that tree and then the second element, run through the assessment tree with that and then of course the third element of risk is morbidity is maybe the quickest and simplest to arrive at an answer with. But thank you Maritza.