Wiki 99213 vs 99214 ANKLE FRACTURE

[RebeccaMoney]

Which level? New problem, established patient. We are not going to do surgery as fracture is stable. Dr ordered and reviewed an xray. Didn't document time. Pt to remain in the CAM boot that they arrived at the visit with. DME script written for a knee scooter.
Thank you.

 

[csperoni]

What would you level for each of: problem, data and risk?

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

 

[twalls]

Which level? New problem, established patient. We are not going to do surgery as fracture is stable. Dr ordered and reviewed an xray. Didn't document time. Pt to remain in the CAM boot that they arrived at the visit with. DME script written for a knee scooter.
Thank you.

I also struggle with this because, I can tell you my Dr.'s like to go 99214 and I could justify it they are still unsure if they are thinking surgery. But if it is stable fracture, they reviewed films and send pt on their way I am saying it's a 99213. Interested to see what others have to say.