Wiki E&M help

Skymom16

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E&M
Hi,
am in need of help ! I need help on what level of E & M is this for GI..

HPi-Pt is here for a follow up for symptoms ,pt has history of annal fissure and hemorrhoids he has been taking Metamucil and it’s working very well. However when he has a overnight shift he doesn’t have a bowel movement and then when he returns home he has up to 5 bowel movements in one day..
Past Hx- address in HPI
Endoscopic studies -2013
Medications -none
Family-negative
Social -alcoholic drinks
ROS-all body - no GI per HPI
Physical examination- vitals
General
Heent
Lungs-cleared
Heart-regulars
Abd- nondisntend
Rectal-skin tags

impression-
48 yrs old male with healing anal fissure . Am recommending starting to take Metamucil one teaspoon daily +2 on his overnight shifts he will follow up in 3 months
Plan -increase Metamucil one tablespoon plus one teaspoon
2.one tablespoon of Metamucil +2 before over night shifts
Follow up in 3 months..
Now the question is he thinks it’s a 99214 ! If I can get help as he would like me to tell him why this is not an 99214.. please ! Thank you!!
 
I think it will go 99213, As there is no moderate Medical Decision Making.


As we can see
History - Comprehensive
Exam - Detailed
MDM - Low Complexity

Some people may think that History & exam is enough for 99214 as it is having 2/3 criteria for established patient.
But some physicians needs MDM as main factor for consideration in determining E&M level.

So I will code above as 99213.
 
Thank you so much! Thats what I thought ! This physician has his history &exam for all patients as comprehensive ! But when it comes to make mdm its always low.. if you don’t mind I have another scenario if you can help me out! Thank you
 
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