Wiki FOLLOW UP AND MDM

[cwilson3333]

Patient returns for follow up visit of his left shoulder pain

During the office visit the doctor does the follow up exam, reviews the MRI with the patient [which had been ordered by the doctor] and his plan of treatment was as follows
Physical Therapy ordered and prescription of anti-inflammatory refilled, and patient to return after his therapy has been completed for another re-evaluation.

Can I bill a 99214 for this visit.
[Does the PT count as a unique test, and the medication count as prescription drug management]

Thanks for any and all replies

CW

 

[Cheezum51]

I would probably code a 99213. You have 1 acute uncomplicated injury (making assumption here) and your data and risk categories are both in the low level. The medication does count as prescription drug management but that's about the only thing that would rise to a moderate risk. However, since it's a refill of I prior RX, there isn't much risk in that IMHO.

Tom Cheezum, OD, CPC, COPC