Wiki 99213??

[HBULLOCK]

I WOULD LIKE TO GET A SECOND OPINION ON THIS DOCUMENTATION PLEASE:

Chief Complaint
rt index finger red and swollen, no fever. started as a small pimple 5 days ago. got much worse in past 24 hours.pt had mrsa of chin july,2009.
family-sib had mrsa infection june 2010

Vital Signs
AGE 18y4.2m
TEMPERATURE 97.7 F
BLOOD PRESSURE 118/68 L Arm
WEIGHT 173.4 lb
WEIGHT (%) 94

Interval History
Illness/Injury since last visit? N
Specialty appointment since last visit? N
Hospitalization, Surgery, ER, Urgent visit since last visit? N
Other
had MRSA july 2009.of chin and was hosp at tufts.
Social History
Household changes? N
Smokers in environment? Y
patient
Pets in environment? Y
1 cat
TB Risk Status? Low
Education Attends school
umass lowell
Physical Exam
General Appearance
WDWN, NAD
Skin
abcess R index finger with sl purulent drainage between first and 2nd mp jts. . decr rom. swelling , erythema + . no axillary glands.
Assessment and Plan
Assesment
abscess R index finger-? mrsa
Plan:
bactrim ds bid
warm soaks, elevate.
rto tomorrow.if not improving will admit for iv therapy. THANKS!!

 

[Orthocoderpgu]

I think you have a 99213

HPI Four
ROS One (EFP HX)

Exam
97-PF Four bullets
95-EPF (Three Systems)

Three Problem points, no date points, low risk = Low MDM

Even if your exam were PF it would still meet 2/3 for a 99213.

 

[jdibble]

I think this is a 99214 -

HPI -4 = Detailed
ROS -2 (skin and constitutional) = Detailed
PFSH -2

Exam - 95 guidelines - 3 areas = EPF

MDM - would be Moderate - the doctor issued an RX so risk is moderate , Problem would be 3 for new problem and no data points.

Established patient - 2/3 elements would be Detailed History, EPF Exam and Moderate Complexity for MDM = 99214