Wiki 99213 or 99214 - This is a follow up visit

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cwilson3333

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This is a follow up visit on a patient who returns for MRI results and surgical scheduling.

IH: The patient continues to have instability and pain in the right knee.

MRI performed shows ACL tear and some other damage in the knee

PLAN: We discussed the treatment options. He has done well with the ACLR that he had on the left side and would like to have a similar procedure done on the right. That is gping to be an ACLR with cadaver graft and PRP injection. I described the procedure, risks, and complications to him; the fact that he might not get better, loss of lim or life, risk of catastrophic outcome, including stiffness, nerve damage, RSD, tendon damage, recurrence of the problem, need for further surgeries, vascular injury, including bleeding, et. The patient understands and the surgery will be scheduled at his convenience.

[I will be using the following diagnosises on this visit which I am able to
code according to the MRI results.]
844.2
836.0
717.89
717.0

What level visit should this be?
 
Maybe I'm missing something but from what you posted you are at best a 99212. I am also confused about the dx you are reporting. Unless the provider specifically references other documentation by name and date you can not use it when coding for their professional services. Each date of service must stand alone.

Your IH is more of a chief complaint but I suppose you could break it down to get 1 element of HPI. I see no review of systems so you would be stuck at problem focused. No exam and MDM appears to be low.

Just my take on it,

Laura, CPC, CPMA, CEMC
 
I was wondering about a ROS or exam as well. I don't see how you would get a moderate complexity for MDM?
 
I agree, I see a level 2 and the dx codes do not add up, you would not use acute injury codes with the the 717 codes, with this documentation.
 
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