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Wiki Otitis Media 99212

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daniel

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Would you squeeze out a level 99212 (established). If your note read.

Chief complaint: Tuggin and pulling at ear

HPI: Inflammation of the ear, pass 2 days.

Plan:otitis media, Augmentin 7 to 10days.
 
I think you already know the answer

Daniel,
You're a smart guy, I think you already know the answer ... but I'll play along.

You have:
Problem focused History: Chief Complaint and Brief HPI (qualify, location, duration)
Moderate MDM: new problem no workup; and Rx

For an established patient you only need to meet 2 of the 3, so you don't need any bullets for exam to arrive at: 99212.

F Tessa Bartels, CPC, CPC-E/M
 
I have to wonder why the physician did not document that he examined/viewed the ear which would serve as the basis for writing a prescription. The limited exam is the "objective" part of the visit and it is not there. Very scanty note in my opinion, but technically fits the 99212 as noted by previous replies.
 
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