belsma23
New
Hello, I'm in dispute on what level code to use on this New Patient note:
Chief Complaint : Wrist Pain - L wrist injury X 1 day
Problems - •Injury of wrist
Medications -None recorded.
Vaccines -Reviewed Vaccines
Pt UTD on vaccinations
Allergies -Reviewed Allergies
LACTOSE: Hives
Past Medical History -Discussed Past Medical History
Surgical History -Reviewed Surgical History
No past surgery
Family History -Discussed Family History
Mother - No family history of
Social History -Reviewed Social History
Mother states no one smokes around child
Vitals -Wt: 35 lbs 8 oz (16.1 kg; 93rd %) 03/16/2016 07:44 pm
O2Sat: 97% Room Air at Rest 03/16/2016 07:40 pm
Pulse: 111 bpm 03/16/2016 07:40 pm
RR: 24 03/16/2016 07:40 pm
T: 99.1 F° ear (37.28 C) 03/16/2016 07:44 pm
Pain Scale: 3 03/16/2016 07:44 pm
Pain Scale Type: Wong-Baker FACES 03/16/2016 07:44 pm
HPI
jumped of the couch landed on floor and held wrist.
few hours ago
no fractures in past
not using
used ice
would not stop screaming
saw Dr. March
ROS
Parent reports fussy but reports good appetite. (S)he reports cough; has allergies. (S)he reports no joint swelling; won't use left hand or wrist or forearm. capillary refill is ok. (S)he reports no redness and no rash; no ecchymosis.
Physical Exam
Patient is a 2-year-old male.
Musculoskeletal System: Left Shoulder: no tenderness, erythema, or warmth. Left Elbow: no tenderness, warmth, erythema, or objective synovitis and good ROM. Left Wrist: pain on palpation. Left Hand: no erythema, warmth, or objective synovitis; no ecchymosis.
Procedure Documentation
Ace Bandage 2"- 6": Applied inch ace bandage to affected area.
Assessment / Plan
1. Injury of wrist - motrin for pain,
S69.82XA: Other specified injuries of left wrist, hand and finger(s), initial encounter
•X-RAY, WRIST, 3 VIEWS
Side: LEFT
Discussion
Patient Instructions
Please follow-up with your Primary Care Provider in 1 week; sooner with worsening symptoms or no improvement.
I'm in dispute with the physician on 99201 vs 99202 --
Any suggestions?
Thank you!
Chief Complaint : Wrist Pain - L wrist injury X 1 day
Problems - •Injury of wrist
Medications -None recorded.
Vaccines -Reviewed Vaccines
Pt UTD on vaccinations
Allergies -Reviewed Allergies
LACTOSE: Hives
Past Medical History -Discussed Past Medical History
Surgical History -Reviewed Surgical History
No past surgery
Family History -Discussed Family History
Mother - No family history of
Social History -Reviewed Social History
Mother states no one smokes around child
Vitals -Wt: 35 lbs 8 oz (16.1 kg; 93rd %) 03/16/2016 07:44 pm
O2Sat: 97% Room Air at Rest 03/16/2016 07:40 pm
Pulse: 111 bpm 03/16/2016 07:40 pm
RR: 24 03/16/2016 07:40 pm
T: 99.1 F° ear (37.28 C) 03/16/2016 07:44 pm
Pain Scale: 3 03/16/2016 07:44 pm
Pain Scale Type: Wong-Baker FACES 03/16/2016 07:44 pm
HPI
jumped of the couch landed on floor and held wrist.
few hours ago
no fractures in past
not using
used ice
would not stop screaming
saw Dr. March
ROS
Parent reports fussy but reports good appetite. (S)he reports cough; has allergies. (S)he reports no joint swelling; won't use left hand or wrist or forearm. capillary refill is ok. (S)he reports no redness and no rash; no ecchymosis.
Physical Exam
Patient is a 2-year-old male.
Musculoskeletal System: Left Shoulder: no tenderness, erythema, or warmth. Left Elbow: no tenderness, warmth, erythema, or objective synovitis and good ROM. Left Wrist: pain on palpation. Left Hand: no erythema, warmth, or objective synovitis; no ecchymosis.
Procedure Documentation
Ace Bandage 2"- 6": Applied inch ace bandage to affected area.
Assessment / Plan
1. Injury of wrist - motrin for pain,
S69.82XA: Other specified injuries of left wrist, hand and finger(s), initial encounter
•X-RAY, WRIST, 3 VIEWS
Side: LEFT
Discussion
Patient Instructions
Please follow-up with your Primary Care Provider in 1 week; sooner with worsening symptoms or no improvement.
I'm in dispute with the physician on 99201 vs 99202 --
Any suggestions?
Thank you!