cwilson3333
Expert
Would like to know what level this IH [interval history] on this patient should be coded:
Patient: Name
DOS: 6-14-2012
IH: The patient comes in for follow-up of the bilateral knees. The left knee is doing great, status post scope. The right knee is giving him trouble with mechanical symptoms such as locking, buckling, popping and pain. He says it feels like the left knee did prior to surgery and he would like to have an arthroscopy. I described the procedure, risks, and complications to him; the fact that he might not get better and might be made worse; risk of catastrophic outcome, including loss of limb or life, risk of infections, clots, arthritis, stiffness, nerve damage, RSD, tendon damage, recurrence of the problem, and the need for further surgeries, etc. The patient understands and the surgery will be scheduled at his convenience.
Doctor's name
DX: 717.2, 715.36, 719.46, V67.59 per coder's choice and MRI results.
Am I looking at a 99212 or 99213?
Thanks,
Cw
Patient: Name
DOS: 6-14-2012
IH: The patient comes in for follow-up of the bilateral knees. The left knee is doing great, status post scope. The right knee is giving him trouble with mechanical symptoms such as locking, buckling, popping and pain. He says it feels like the left knee did prior to surgery and he would like to have an arthroscopy. I described the procedure, risks, and complications to him; the fact that he might not get better and might be made worse; risk of catastrophic outcome, including loss of limb or life, risk of infections, clots, arthritis, stiffness, nerve damage, RSD, tendon damage, recurrence of the problem, and the need for further surgeries, etc. The patient understands and the surgery will be scheduled at his convenience.
Doctor's name
DX: 717.2, 715.36, 719.46, V67.59 per coder's choice and MRI results.
Am I looking at a 99212 or 99213?
Thanks,
Cw