? Level on office visit

[cnramsey]

Patient was seen two days before this apt by same provider for same problem. Provider has 99213???? Thanks again

Referring Provider: NCH ER
Primary Provider:

CC: 2d F/U R knee.

History of Present Illness:
injured rt knee twisting injury while dancing 4 days ago. she has increased swelling and pain. she is in a splint. she has continued pain worse with ambulation.

Review of Systems
See HPI

Vital Signs:

Patient Profile: 27 Years Old Female
Height: 65.75 inches
Weight: 256 pounds
BMI: 41.78
Temp: 97.8 degrees F tympanic
Pulse rate: 84 / minute
Pulse rhythm: regular
BP sitting: 140 / 94 (left arm)
Cuff size: regular

Vitals Entered By: Physical Exam

General:
well developed, well nourished, in no acute distress.
Extremities:
rt knee pain. she has swelling distal knee. she has limited rom due to swelling and pain.
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.


Impression & Recommendations:

Problem # 1: KNEE SPRAIN, RIGHT (ICD-844.9)
will continue to use gentle rom. will ice. will use nsaids. will follow.

[FTessaBartels]

This documentation is for an EPF history, EPF exam and low complexity MDM. That equals a 99213.

Hope that helps.

F Tessa Bartels, CPC, CEMC

[sumeet_lawhare@yahoo.com]

yes even it follow up visit than also it qualify for 99213 cause. the provider is reviewing the body systems .. so we have Ros and HPI element to make it EPF ... and physical EPF.. and low MDM to make 99213..