Wiki I know this is a stretch

[daniel]

3 Or 4

Don't have a good history, but the MDM is met for a level four. Kids 17yrs of age, diagnosis with bronchitis. Given a prescription.

But using the 1995 guidelines, could one argue for a level four exam on this example below.

PE: on exam she is afebrile. Her ear canals are clear and her TMs are normal. His nares are congested. Her pharynx is mildly injected. There are no exudates. She is very hoarse and does have a croupy-type cough. her lungs reveal some rhonchi. There are no wheezes or rales.

Thinking.

ENT
&
Respiratory

for the 2-7 on the exam.

I know it's a stretch (regarding the documentation). Looking for some opion's.

Respectfully
Daniel

 

[FTessaBartels]

99213

Daniel,
I know that Rx bumps up your MDM RISK to "Moderate" ... but I wouldn't stretch this VERY focused exam to "detailed" even with the 1995 guidelines.

I know that 1995 shows 2-7 systems for both Expanded Problem Focused and Detailed ... but our internal guidelines are:
2-4 = Exp Prob Foc
5-7 = Detailed

I'd code it as 99213.

F Tessa Bartels, CPC, CPC-E/M

 

[daniel]

I sent this visit out as a level 3, just trying to see if anyone out there would get a level four exam out of this. Just looking at what people's opion are.

Respectfully
daniel, CPC

P.S- I agree with everthing you put.