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dsmith06351

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How would you determine medical decision making on this encounter? I am doing some audits for our physcians and would love a second opinion and your rationale.

It was a detaild history and comprehensive exam

the impressions and plans are

Elevated lead level plan - level < 3
Chapped hands/eczema plan - cetaphil lotion
Lacerated lip plan - mederma at hs after healed, bacitracil for now

during the exam foreign body found in right ear - removed with forceps.


Any help would be greatly appreciated.

Denise Smith CPC, CEMC
 
Is this a little one? Chapped hands, FB in ear, lacerated lip...... But most importantly a potential for lead poisoning? This is serious.

I don't know the setting? If Office, New Vs. Est.? Or ED?

I'm going to guess Est. Office:

The FB to the ear is most likely a new problem (no additional workup). +3
The other conditions (on the low end) are multiple stable est. problems. +2
Extensive number of management options

Lead levels
Minimal amount of Data (lab)

Don't know the background for the lead levels. Unable to determine if the pt is symptomatic or not, so can't really determine risk to patient. However, FB's are often considerd complicated injuries and a Mod Risk to the pt.
Moderate Risk to Pt.

99214
 
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