One coder says 99212 the other says 99213.....
This patient was seen by another provider in the same clinic 2 weeks prior to this visit with similar complaints.
CC: Vag discharge.
History of Present Illness:
pt recently had vaginal yeast infection. was treated and cleared. she then had uti and was put on abx. now she is itching and has vaginal discharge.
Review of Systems
well developed, well nourished, in no acute distress.
clear bilaterally to auscultation.
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
alert and cooperative; normal mood and affect; normal attention span and concentration.
Height: 63.75 inches (159.38 cm)
Weight: 112.12 pounds
Temp: 96.6 degrees F tympanic
Pulse rate: 84 / minute
Pulse rhythm: regular
BP sitting: 108 / 78 (left arm)
Cuff size: regular
Vitals Entered By:
Impression & Recommendations:
Problem # 1: VAGINITIS (ICD-616.10)
will treat with diflucan. will call if not getting better.
The following medications were removed from the medication list:
Levaquin 250 Mg Tabs (Levofloxacin) ..... 1 po qday 1 week
Medications Added to Medication List This Visit:
1) Diflucan 150 Mg Tabs (Fluconazole) .... One tab po daily
DIFLUCAN 150 MG TABS (FLUCONAZOLE) one tab po daily #2 x 0
Entered and Authorized by:
Method used: Faxed to ...
99213 - Rx management with a new medication for a new problem/complication.
Hx = 1 HPI, 1 ROS = expanded problem focused
PE = I wouldn't use as there was no exam of the organ system referred in the Hx.
MDM = new problem, Rx management moderate
Michelle Worcester, CPC, CEDC, CEMC
if the body system with problem has been examined than you would have considered rest other for PE...???????
i consider PE .... cause provider is working toward the general health of the patient apart from the problem.... so for that he should get paid...
and vaginitis is a self limited problem ... so MDM will go low ...
but if we consider PE EPF and Hx EPF than we get 99213 taking MDM low.....
Please give some suggestion...