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Wiki Need help with MDM level

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mcarrillo

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One of my docs is seeing a patient for a pre-op office visit and wants a 99214. He meets the criteria in the History and even the exam. It is for a knee replacement. My trouble is the MDM. He gives arthritis (chronic) and chondromalacia (chronic). Can I count these as two different Dx's addressed, or since it's a follow-up for both for the surgery, do I cound only one problem addressed?

I always have a problem with the joint issues like arthritis, synovitis, bursitis, chondromalacia, tendon/ligament sprains when they are in one joint but the doc is treating and addressing both for one joint (knee, shoulder, etc.)

Any suggestions welcomed. :)
 
For an established pt level it is two of three. So, if you have history and exam at 4 then that is two of the three, no?
 
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