Contraception consults

Greenpiper

Contributor
Messages
14
Location
Spokane, WA
Best answers
0
My fellow coder and I are thinking that the MDM for this visit only supports a 99212. Does anyone have a different thought and reason why it may be higher?
Thank you

Primary Provider:
CC:
discuss BC.
History of Present Illness:
In today to discuss contraception, has one partner. Menses are regular. Using condoms. Desires Nexplanon. Does not smoke, no history of clot disorders
Past Medical History:
Reviewed history from 12/02/2011 and no changes required:
Healthy
Past Surgical History:
unremarkable
Risk Factors:
Smoked Tobacco Use: Never smoker
Smokeless Tobacco Use: Never
Review of Systems
General

Denies fever and chills.
CV
Denies chest pain or discomfort, shortness of breath with exertion and palpitations.
Resp
Denies cough and shortness of breath.
GU
Denies missed periods and pelvic pain.
Derm
Denies rash.
Neuro
Denies numbness and tingling.
Psych
Denies mental problems.
Vital Signs:
Patient Profile:
LMP: 10/06/2019
Height: 66.25 inches (161.29 cm)
Weight: 132.75 pounds
BMI: 21.26
BSA: 1.69
O2 Sat: 100 %
Temp: 98.4 degrees F temporal
Pulse rate: 84 / minute
Resp: 18 per minute
BP Sitting: 112 / 60 (left arm)
Vitals Entered By:
Physical Exam
General:

Well appearing adolescent, no acute distress
Lungs:
Clear to ausc, no crackles, rhonchi or wheezing, no grunting, flaring or retractions
Heart:
RRR without murmur
Neurologic:
Neurologic exam grossly intact
Psychiatric:
alert and cooperative
Impression & Recommendations:
Problem # 1:
Contraception management (ICD-V25.09) (ICD10-Z30.9)
Assessment: New
Procedure discussed with patient including irregular unpredictable menses, wishes to proceed with referral. Use condoms or abstinence prior to insertion.
Orders:
Nexplanon (Nexplanon)
Electronically signed by
______________________________________________________________________
 

atilton

New
Messages
4
Location
Warren, MI
Best answers
0
To me these types of scenarios are hard. Most of our docs code these as 99213. I can see how this could be Low decision making if it's a new problem for the pt and if the provider interprets the Risk as Low due to Minor Surgery with No Risk Factors. I also see it being a Moderate decision making if it's a new problem for the pt and the provider interprets the risk as moderate due to rx management for prescribing the nexplanon which is an rx drug that has to be ordered for the pt before they can put it in. I am really curious how other coders would see this as well.
 
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