Wiki E/M Visit Level


Hamilton, VA
Best answers
Will someone audit this visit for me on a follow visit on etablished patient?

Patient name
Date of Service

IH: The patient comes in for follow-up of the right knee. He has done PT with no relief of his symptoms. He would like something done to fix the right knee and that is going to be an arthroscopy.

P: I described the procedure, risks, and complications to him of an arthroscopy. The fact that he might night get better and might be made worse; risk of catastrophic outcome including loss of lim or life; risj of infections, clots, arthritis, stiffness, nerve damage, RSD, tendon damage, recurrence of the problem, need for further surgeries, etc. The patient understands and the surgery will be scheduled at his convenience.

Doctor's Name

Does this meet a 99213?

No, this is only a level 2 visit. History is level 2, there is no exam documented, and although mdm is level 3, this can only support a 99212.
I agree its 99212 I get this a lot with my orthopedic doctors. However if they were to document the information needed for counseling time the note above describes treatment, prognosis & risk factors