pfsh help

alices

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Stockton, CA
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can someone please help?? I seem to be having a few problems lately when it comes to the HPI and now the PFSH, what level would you all give.

cc- sob, hpi-pt presents c/o sob has chronic asthma, pt buys his meds from mexico flea mkts, pt has been sob for several days, getting worse, assoc-cough no fevers and no modifying factors, ros-is complete, pfsh-asthma social hx is chked=2, exam-complete
dx is status asthmaticus, meds given albuteral, atrovent, prednisone, with 3 breathing tx.,

my problem I think that I am having is that if it is a chronic condition then it is a 2 estab priob worsening, and if there is no other dxs/labs or anything to put into the table B , table C we have the meds/treatment the only level is the 99282 and for me it just doesn't look right/feel right I don't want to over code but I really don't want to under code either, I hope that someone will help me with this, hopefully I explained it right..thanks alice
 
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4,466
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Milwaukee WI
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Are you having problem with History or MDM?

I'm somewhat confused by your post. Is your problem with determinining the level of history? Or is it the MDM?

Can you clarify?

F Tessa Bartels, CPC, CEMC
 

DeeCPC

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Austin, TX
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What do you mean ROS-is complete and exam -complete? Is that what the doctor is stating in the note ("I obtained a complete ROS and performed a complete exam"? or are you counting the elements and just stating that it is complete?

It would be easier if we could see the actual note -redacted.
 
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