need help w e/m dictation


Kearney, Missouri
Best answers
Below is what the doctor dictated and is wanting to charge a 99212. There is no exam dictated. I know you have to meet 2 out of 3 for the level, but do you need some kind of exam for this visit to be billed at all???

This patient is not doing any good with her right ankle. It persists with chronic swelling throughout the ankle.
X-RAY: X-rays today show severe advanced degenerative change throughout the entire right ankle and possibly minimal lateral shift of the talus but very, very minimal. She has got a slow union, and I think she is developing a union of the distal fibula but the fracture line is still visible.
PLAN: The patient vehemently denies any trouble with ankle pain at all before this accident; however, a lot of this arthritis was there prior to the accident and I suppose this fracture has stirred all of this up. I am at somewhat of a loss as to why she is not getting better. Possibly, she is just slow healing. In any event, I feel that a 2nd opinion from a foot and ankle specialist would be in order at this time. She is referred to Dr. Susan B for further evaluation and treatment.

Thanks for any and all opinions!!

Liberty Orthopedics