AZ_coder22
Contributor
Hi all,
I'm wondering if I can get some feed back with regards to what level e/m this visit would be coded as. The provider documented a 99214, but I feel like it would be more along the lines of a 99213.
Patient is 39 year old female. established patient seen at urgent care center
CC
t comes in today for sore throat, chest congestion, cough, and hoarseness.
HPIatient reports
sore throat [onset 1 week. duration 3 days, denies hurts to swallow]
chest congestion
cough [onset acute, frequency:random; char: reports suptum-greenish, course cough]
Hoarseness[onset acute. assoc sx reports cough and nasal congestion]
Fatigue
Achy [reports joints, generalized]
Sneezing
Sinus Congestions [onset, acute. char: reports worsening, drainage; location reports bilateral. assoc sx reports cough. Free text-claritin no help]
PMH- review past med HX no changes
ROS
Constitutional-patient reports: fatigue, achy. denies fever
ENT/Mouth-patient reports: sinus congestion
Respiratory-patient reports: cough
Allergy/Immune-patient reports: sneezing
Vitals: BP: 122/86 mmHg, Pluse: 68bpm, RESP: 15 breaths/min TEMP: 98.8, O2SAT: 98%
Exam
General-Abnormal: patient is in distress, secondary to sxs one week, w/ sxs getting worse. Denies fevers or chills. Hoarseness, minor nasal congestion. coughing occ. Has seasonal allergies.
Skin, Hair, Nails-Normal: normal skin temp upon palpation. Normal skin moisture. No rashes noted. Normal color noted
Head-Normal:normocephalic, Face is grossly normal. No evidence of trauma
Eyes-NormalERRLA, sclera normal. No corneal abnormalities noted. Lids and lashes are normal. Anterior chamber normal.
Ears-Normal: Normal TM(s). Hearing grossly intact bilaterally. Normal pinna bilaterally. Normal external canals bilaterally.
Nose-Abnormal:Boggy nasal mucosa both nasal passages. Moderate amount of clear nasal discharge noted
Oral Pharynx-Abnormal: post pharynx with erythema
Neck-Normal: no deformity of neck. Neck is supple. No palpable lymphadenopathy
Chest/Lungs-Abnormal: Coarse, dry cough
Cardiac-Normal: heart normal to auscultation, Normal heart rate noted, normal rhythm, normal peripheral pulses noted.
Neurological-Normal: Patient alert and oriented. Normal gait, coordination/balance normal
Musculoskeletal-Normal: Normal posture, normal gait
Psych-Normal: insight appears normal. normal behavior noted. mood appears to be normal, affect normal.
Procedures
Med Administration
Written consent obtained.
verbal consent obtained
the risks and benefits were explained. The patient appears to understand and granted permission to perform procedure. Patient verified.
Dexamethasone was administered. Dose verified as 5mg orally. Patient was discharged home on own accord.
A/P
Allergic rhinitis
Allergies
Turbinate hypertrophy
Cough
Drink plenty of fluids. Get plenty of rest. Return to clinic if signs of symptoms persist or worsen. Use cool mist humidifier at bedside. Don't share glasses or eating utensils. Wash hands frequently. Please use over the counter cough remedies. discuss the best options with your pharmacist
Perscribed predninsone 20 mg tablet. Take 2 tablets 1 time per day for 5 days. total qty: 10 tablets. no refills. allow substitutions.
I'm wondering if I can get some feed back with regards to what level e/m this visit would be coded as. The provider documented a 99214, but I feel like it would be more along the lines of a 99213.
Patient is 39 year old female. established patient seen at urgent care center
CC
t comes in today for sore throat, chest congestion, cough, and hoarseness.HPI
atient reports sore throat [onset 1 week. duration 3 days, denies hurts to swallow]
chest congestion
cough [onset acute, frequency:random; char: reports suptum-greenish, course cough]
Hoarseness[onset acute. assoc sx reports cough and nasal congestion]
Fatigue
Achy [reports joints, generalized]
Sneezing
Sinus Congestions [onset, acute. char: reports worsening, drainage; location reports bilateral. assoc sx reports cough. Free text-claritin no help]
PMH- review past med HX no changes
ROS
Constitutional-patient reports: fatigue, achy. denies fever
ENT/Mouth-patient reports: sinus congestion
Respiratory-patient reports: cough
Allergy/Immune-patient reports: sneezing
Vitals: BP: 122/86 mmHg, Pluse: 68bpm, RESP: 15 breaths/min TEMP: 98.8, O2SAT: 98%
Exam
General-Abnormal: patient is in distress, secondary to sxs one week, w/ sxs getting worse. Denies fevers or chills. Hoarseness, minor nasal congestion. coughing occ. Has seasonal allergies.
Skin, Hair, Nails-Normal: normal skin temp upon palpation. Normal skin moisture. No rashes noted. Normal color noted
Head-Normal:normocephalic, Face is grossly normal. No evidence of trauma
Eyes-Normal
ERRLA, sclera normal. No corneal abnormalities noted. Lids and lashes are normal. Anterior chamber normal.Ears-Normal: Normal TM(s). Hearing grossly intact bilaterally. Normal pinna bilaterally. Normal external canals bilaterally.
Nose-Abnormal:Boggy nasal mucosa both nasal passages. Moderate amount of clear nasal discharge noted
Oral Pharynx-Abnormal: post pharynx with erythema
Neck-Normal: no deformity of neck. Neck is supple. No palpable lymphadenopathy
Chest/Lungs-Abnormal: Coarse, dry cough
Cardiac-Normal: heart normal to auscultation, Normal heart rate noted, normal rhythm, normal peripheral pulses noted.
Neurological-Normal: Patient alert and oriented. Normal gait, coordination/balance normal
Musculoskeletal-Normal: Normal posture, normal gait
Psych-Normal: insight appears normal. normal behavior noted. mood appears to be normal, affect normal.
Procedures
Med Administration
Written consent obtained.
verbal consent obtained
the risks and benefits were explained. The patient appears to understand and granted permission to perform procedure. Patient verified.
Dexamethasone was administered. Dose verified as 5mg orally. Patient was discharged home on own accord.
A/P
Allergic rhinitis
Allergies
Turbinate hypertrophy
Cough
Drink plenty of fluids. Get plenty of rest. Return to clinic if signs of symptoms persist or worsen. Use cool mist humidifier at bedside. Don't share glasses or eating utensils. Wash hands frequently. Please use over the counter cough remedies. discuss the best options with your pharmacist
Perscribed predninsone 20 mg tablet. Take 2 tablets 1 time per day for 5 days. total qty: 10 tablets. no refills. allow substitutions.