Is this a a 99212

daniel

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Would you squeeze out a level 99212 (established). If your note read.

Chief complaint: Tuggin and pulling at ear

HPI: Inflammation of the ear, pass 2 days.

Plan:eek:titis media, Augmentin 7 to 10days.
 

HCCCoder

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Yes, for est. pt you need to meet 2 out of 3 (hx, pe, mdm).
Even though the PE is not documented, but there is a CC, the hx level is PF (brief HPI, no ROS, no PFSH). The MDM is SF, because of 1 self-limited problem with Rx drug management.
Even if you want to consider the "otitis media" as a new problem, still, the LOS would be 99212, because your hx level is SF and there is no PE.
Hope this will help
 

erjones

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Would you squeeze out a level 99212 (established). If your note read.

Chief complaint: Tuggin and pulling at ear

HPI: Inflammation of the ear, pass 2 days.

Plan:eek:titis media, Augmentin 7 to 10days.
You have a brief hx and moderate mdm, you only need 2 of 3 elements to meet the 99212 level.
 
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