Office Visit Level

[cnramsey]

When I work this visit up I get a 99212 but the provider feels that since he did a prescription that this makes it a 99213. Any input would be appreciated.

Primary Provider:

CC: bug bite R forearm 06/24/12.

History of Present Illness:
pt got a bite two days ago on rt arm. he/she has had itching and warmth. he/she has been using benadryl x 4. he/she denies any infectious process.

Review of Systems
See HPI

Vital Signs:

Patient Profile: 60 Years Old Female
Height: 61 inches
Weight: 146 pounds
BMI: 27.69
Temp: 97.8 degrees F tympanic
Pulse rate: 64 / minute
Pulse rhythm: regular
BP sitting: 100 / 76 (left arm)
Cuff size: regular

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Skin:
rt forearm pink and slightly swelling.


Impression & Recommendations:

Problem # 1: INSECT BITE (ICD-919.4)
will put on hydrocortisone bid. will put on medrol dose pack. will use cold compress.

Medications Added to Medication List This Visit:
1) Medrol (pak) Tabs (Methylprednisolone tabs) .... Take as directed

[MNorvik]

I would code it as 99212 because the exam was problem focused. The exam only included the problem area. Reference used was coders desk reference.

Originally Posted by cnramsey

When I work this visit up I get a 99212 but the provider feels that since he did a prescription that this makes it a 99213. Any input would be appreciated.

Primary Provider:

CC: bug bite R forearm 06/24/12.

History of Present Illness:
pt got a bite two days ago on rt arm. he/she has had itching and warmth. he/she has been using benadryl x 4. he/she denies any infectious process.

Review of Systems
See HPI

Vital Signs:

Patient Profile: 60 Years Old Female
Height: 61 inches
Weight: 146 pounds
BMI: 27.69
Temp: 97.8 degrees F tympanic
Pulse rate: 64 / minute
Pulse rhythm: regular
BP sitting: 100 / 76 (left arm)
Cuff size: regular

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Skin:
rt forearm pink and slightly swelling.


Impression & Recommendations:

Problem # 1: INSECT BITE (ICD-919.4)
will put on hydrocortisone bid. will put on medrol dose pack. will use cold compress.

Medications Added to Medication List This Visit:
1) Medrol (pak) Tabs (Methylprednisolone tabs) .... Take as directed

[aaron.lucas]

no, looks like the 99213 was good, the history was expanded problem focused, and the prescription drugs are considered "moderate" on the table of risk (risk level is moderate), the problem is new to the examiner with no additional workup, and prescription was given (multiple dx/tx options), so your MDM is actually moderate. the history and the MDM are enough to give you 99213.