Wiki looking for level please

[wynonna]

Level 2 or 3?
Chief Complaints:
1. Nasal congestion/sinus/rhinitis.
HPI:
general:
Patient is status post Vivaer procedure on November 2019 followed by Latera implants August 13, 2021. She is still having tenderness along her nasal dorsum. She feels the nasal congestion may be slightly improved. She denies rhinorrhea or sneezing.

Assessment:
1. Nasal valve collapse - J34.89 (Primary)
Continued nasal congestion and continued soreness following Latera implants.

Plan:
1. Nasal valve collapse
Notes: No further intervention indicated and patient not interested in any subsequent procedures; follow-up as needed.

Exam done on Nose but not included her.

 

[b.cobuzzi]

Patient has a chronic problem that is not in control, that is Moderate under Problem.
Although surgeon offered surgical option, patient declined this option. Your doctor needs to do a better job with listing the plan of care and then indicate that patient denied the option offered. And your doctor has to define whether the surgery is minor or major surgery (it does not go by the global days, it is surgeon defined) and if it is with no risk factors or with risk factors (and list a few), so you can determine if the risk is Low, Moderate or High. If the Risk is low, meaning minor surgery with no risk factors, the visit is 99213. If risk is moderate, meaning the surgery is either minor surgery with risk factors or major surgery without risk factors, the visit is 99214. And if the risk is high, meaning that the surgery is major with major risk factors the visit is still 99214 since the problem is moderate limiting the encounter to no higher than a level 4.

Wynonna, if you still are having problems, email me and we can discuss. b.cobuzzi@att.net

 

[wynonna]

thank you kindly, Barbara.
You always have good ideas.