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mcdream

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99213 or 99214?
HPI: 3 days of viral URI symptoms with cough. She has asthma. No red flag symptoms, well appearing and breathing comfortably. Unlikely to be PNA without fevers, chest pain, SOB. Flu testing would not change management at this time, but I recommend that she test for covid at home. If positive would qualify for Plaxlovid. She will call back if covid positive. Recommend treating for asthma exacerbation.
A/P: Exacerbation of Asthma- Prednisone 20mg, Benzonate 100mg, Dextromethorphan-guaifenesin 10mL.
Thanks in advance
 
Chronic with exacerbation and prescriptions.
4 if you want to be generous since the provider called it, " Exacerbation of Asthma".
 
I agree. Without the provider assessment stating exacerbation of asthma, I probably would have considered this an acute, uncomplicated problem. However, the clinician is stating exacerbation of asthma, so I would also code this as level 4.
Problem: moderate for chronic with exacerbation
Data: minimal
Risk: moderate for prescriptions
 
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