midnight1995
Networker
I have reviewed all AMA and other resources and if a provider orders/results and bills for Lab CPT this cannot be counted in Data ordered. The provider is indicating this is incorrect: The progress note my findings were 99203, as well as the 3 lab In-house that was billed. If you give 3 ordering of each unique test - this would up the MDM to 99204.
Chief Complaint: Nr Walkin 940 cold.
HPI: constitutional: presented for acute visit due to stuffy nose and sore throat. She reported that her symptoms began three days ago, with worsening stuffiness in the morning and waking up throughout the night. She described additional drainage and occasional cough but denied any SOB. Works as a softball coach at school and expressed concern about potentially passing her illness to the students and her team. Noted that using a humidifier has helped relieve her symptoms. Came in primarily to get tested for illness due to her work exposure and mentioned that her head coach advised her to take a day off. No known sick contacts. These symptoms and concerns have probated her to seek care and guidance on managing her condition and minimizing transmissions to others.
ROS; General/Constitutional: Change in appetite admits and ENT: nasal congestion admits. Sore throat Patient reports symptoms tarting 2 days prior to arrival
Medical, surgical, Hospitalizations, family and social History: all document
Medications: None and Allergies: verified.
Vitals are all documented
Exam: General Examination:
Oral cavity: Mild erythema and clear postnasal drip in the oral pharynx without edema
Lymph nodes; No anterior cervical lymphadenopathy.
Heart: normal heart exam
Lungs: Normal lung exam
Labs: Note In-house labs are being billed
Chief Complaint: Nr Walkin 940 cold.
HPI: constitutional: presented for acute visit due to stuffy nose and sore throat. She reported that her symptoms began three days ago, with worsening stuffiness in the morning and waking up throughout the night. She described additional drainage and occasional cough but denied any SOB. Works as a softball coach at school and expressed concern about potentially passing her illness to the students and her team. Noted that using a humidifier has helped relieve her symptoms. Came in primarily to get tested for illness due to her work exposure and mentioned that her head coach advised her to take a day off. No known sick contacts. These symptoms and concerns have probated her to seek care and guidance on managing her condition and minimizing transmissions to others.
ROS; General/Constitutional: Change in appetite admits and ENT: nasal congestion admits. Sore throat Patient reports symptoms tarting 2 days prior to arrival
Medical, surgical, Hospitalizations, family and social History: all document
Medications: None and Allergies: verified.
Vitals are all documented
Exam: General Examination:
Oral cavity: Mild erythema and clear postnasal drip in the oral pharynx without edema
Lymph nodes; No anterior cervical lymphadenopathy.
Heart: normal heart exam
Lungs: Normal lung exam
Labs: Note In-house labs are being billed
