Level e/m opinions please

HBULLOCK

Guest
Messages
282
Location
SALEM NH
Best answers
0
Complaint
f/u skin issues spot on back uses

would like referral to derm

also still has lump R lower chest. - needs to rt spirito for ? of surgical removal.

tore acl- never had it repaired. never f/u with ortho.


Vital Signs
AGE 21y11.6m
TEMPERATURE 97.3 F
BLOOD PRESSURE 114/72
WEIGHT 136 lb
BMI 21.7

Interval History
Illness/Injury since last visit? N
Specialty appointment since last visit? N
Hospitalization, Surgery, ER, Urgent visit since last visit? N

Social History
Pets in environment? N
Firearms in environment? N
TB Risk Status? Low
Education Attends school
Financial instability? N
Comments

pt immigrated to uS at age 8 in 1997 , needs ppd for college

Physical Exam
General Appearance

‎WDWN, NAD

Skin

tinea versoicolor over entire torso, back, hypopigmented dry and scaly. 4 cm soft mass R lower chest.

Assessment and Plan
Assesment

R acl needs f/u

tinea versicolor

mass R lower chest


Plan:

ortho f/u

derm consult

surgical f/u

Call/Return if worse or not better in:

RTO if worse sxs, new sxs or not improving.

Patient came in for his skin issues but then dr referred him to f/u on 2 other issues that were previously addressed that patient never saw specialist for. I believe this is a 99212. Dr wants to charge a 99214. any thoughts?? thanks :)
 

mls101163

New
Messages
3
Best answers
0
Based on the documentation above and 95 guidelines......I would code this report as a 99213. The HPI is lacking so you would need to pull something for ROS, making the History, expanded prob focused,
the Exam is expanded problem focused and the MDM is moderate..........you need 2 out of three so I would code this as a 99213.

Let me know if you agree,

Mary Lou Saunders, CPC
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
99213

I agree with Mary Lou. 99213. You have expanded problem focused history, and an expanded problem focused exam.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Top