We have a patient who came in with an arm injury. The nurse did temp, bp and weight. HPI states played multiple sports this w/e, very sore yesterday and this am, better now but still sore over distal femur with flexion.
Works construction using nail gun daily right hand.
PE: Gen appearance wdwn, nad
Extremity: r elbow sl swollen over dorsum of r humerus/triceps tendon with ttp, FROM with some stiffness on full flexion, equal hand grasps.
Neuro: neuro circ intact distally
Assessment: tendonitis R tricep
Plan: rest, ice, ibuprofen
To me this looks like a 99212 since mdm is straightforward. Doctor wants me to bill 99213. What do you think???? thanks
Works construction using nail gun daily right hand.
PE: Gen appearance wdwn, nad
Extremity: r elbow sl swollen over dorsum of r humerus/triceps tendon with ttp, FROM with some stiffness on full flexion, equal hand grasps.
Neuro: neuro circ intact distally
Assessment: tendonitis R tricep
Plan: rest, ice, ibuprofen
To me this looks like a 99212 since mdm is straightforward. Doctor wants me to bill 99213. What do you think???? thanks