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Wiki E/M coding and IUD check Question

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pcorr45

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I'm getting some mixed information on the level of E/M this visit should be, so I'd thought better to ask for help!

Patient comes in for IUD check. During visit patient states partner feels poking during intercourse. Pelvic exam completed. Patient requests strings to be cut. 1 cm of strings are trimmed. No complications. Urine pregnancy test ordered and resulted.

Thank you in advance for the help! Also, if anyone is open to having a Mentee please let me know! I would love to be able to find a mentor who has experience in outpatient, family planning, obgyn coding.
 
What is your determination of:
Problem
Data
Risk
Once you determine the level of each, you will have your overall level. If there is something you are debating between, please explain.
 
csperoni said:
What is your determination of:
Problem
Data
Risk
Once you determine the level of each, you will have your overall level. If there is something you are debating between, please explain
Click to expand...
This is what I came up with:

Problem: Low (1 acute uncomplicated illness)
Data: Minimal/Limited (Since Urine pregnancy test was the only order and is not counted toward data)
Risk: Low

The part that has me confused is the trimming of the strings. I'm not sure if that increases the problem or risk level.
 
I agree with your assessment of problem as low and data as minimal.
Regarding risk, I personally would consider trimming the string of an already placed IUD as minimal risk of morbidity. Low risk seems a bit of a stretch.
I would wind up with:
99212
99459
If documentation supported a higher level of problem, I would consider 99213, 99459.
But if I have a note of:
Pt presents today for IUD followup. States partner is feeling poking during intercourse and is requesting string be trimmed.
Exam: pelvic exam details here with no abnormal findings
POCT urine UCG: negative
Assessment & Plan: IUD in place. Strings trimmed 1cm per patient request. Follow up PRN.
I would code that as level 2 visit and 99459.
 
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