Help with E/M Level

jen11976

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What would you code the following subsequent hospital visit?

69 y/o f with 6 day hx of low back pain which radiates down L leg. VAS 5-6/10. Radiation down to L knee, occasionally to mid-calf area. No associated numbness/weakness. Currently on Flexaril with no significant relief.
MRI pending. CT scan - multiple disc bulge, facet hypertrophy
PMH: HTN, CAD, s/p stents, CVA x 2
All: Codeine, PCN

Exam: Patient in bed. Left sacroiliac joint tenderness, left piriformis spasm +, single leg raise normal bilaterally, Ext. both normal bilaterally, no significant neuro deficits

Imp: 69 y/o F with acute onset LBP with some radiation down left leg to knee. MRI pending. Sacroiliac pain and Left piriformis spasm.
-Continue conservative care with PT and meds
-Patient may benefit from OSIJ/Piriformis Trigger Point injection
-Not a candidate for epidural due to anticoagulation
-Patient can be followed at our clinic

Any help is greatly appreciated!
Thank you!
 

LLovett

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As much as I hate to say it,I would go with 99231. I'm having history envy, I wish my providers would give me a fraction of that on their subsequent care notes.

Great history but the exam is problem focused (based on 97) and the mdm is low.

Just my take on it,

Laura, CPC
 
Last edited:

pratap82

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99231..

I would go with 99231 as well, as only two out of three key somponents is enough to determine 99231.

I got the two components in examination and MDM.

Problem focussed examination and LOW RISK because of PT.

regards,
:p
 
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Milwaukee WI
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Is this a discharge?

I'm just wondering if this is a discharge since the last line is that patient can F/U in clinic.

F Tessa Bartels, CPC, CEMC
 
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