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Wiki Follow-up to ER visit

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Stonebr

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Here's my conundrum.....MD thinks it's worth a 99213, I say 99212:

S: Here with right ankle pain;he twisted it. Went to the ER over the weekend. Negative x-ray but very swollen. He states he has broken it in the past.

A&P: Gave him a script for PT for this severe right ankle sprain.

That's it for the note, am I wrong?

Thanks in advance for your response.
 
I agree with you.

S: Here with right ankle pain (chief complaint);he twisted it (context). Went to the ER over the weekend.Negative x-ray(mod factor). but very swollen (1 exam element). He states he has broken it in the past(past history).

A&P: Gave him a script for PT for this severe right ankle sprain.

New problem no work up 3 points
PT Low

So you have PF history, PF exam, Low MDM.

If you could pull 1 ROS out of the history it would be a 3. I debated using very swollen as an ROS but that is more of an exam element in my opinion.

Laura, CPC, CEMC
 
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