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Wiki 99213 or 99214

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cwilson3333

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290
Location
Hamilton, VA
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Will someone audit this claim for me? 99213 or 99214

IH: The patient comes in for follow-up. He has a sharp stabbing pain in the knee with
every step.

The MRI done last week shows damage to the meniscus, but more importantly, an
insufficiency fracture of the medial tibial plateau.

P: Increase his vitamin D and calcium. He is to use a wheelchair or walker. He will
limit walking and no work for a month. I would like to get a DEXA scan on him.
He will check back in a month.

RX given for: Percoset

Orders for: DEXA Scan [Dx: Osteoporis]
Walker/Wheelchair
 
If the physician did not do any exam then I don't think you could even get a 99213 out of it as I don't see anything you could use as a ROS. You could use the "stabbing pain" as a HPI but I don't see any ROS or exam. I would code it as a 99212.
 
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