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Wiki 99212 vs 99213-Would like someone

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cwilson3333

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Hamilton, VA
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Would like someone to check me on this level of service

Patient Name
Date of Service



IH: Patient comes in for follow-up of the right knee. PT has not made much of a
difference.

PE: It continues to be tender at the medial fact of the patella. He has tenderness
over the MJL, positive McMurray. The pain from the shin splints is gone.
He has no tenderness there.

A: Internal Derangement

P: MRI of the right knee for internal derangement.
Script written for MRI.



Dr. Name
Initials of Dr/Transcriber
 
I would argue that the MDM is Low, but would like better documentation to confirm that this is an established problem, not responding to treatment.

Because the History and Exam are both problem focused, this is only a 99212. The provider should document a bit more history, and the exam could easily include vitals, assessment of general appearance, assessment of the skin and/or neurologic findings. This could easily meet the requirements for a level 3 if it were better documented.
 
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