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Wiki please help to code this

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dan528i

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Hello everyone,

I need your help coding this please:

12y F present at GYN with compl: L breast bigger then right one.
Dr. Notes:
PH Completed
HPI completed
PH and GYN Hist Comp. as much as possible
OB Hist=NON
FH and Social Hist=Completed
ROS=Completed
Physical Exam VEry limited=virgin
BREAST EXAM SOFT W/ NO MASSES.

I HAVE NO IDEA HOW TO CODE THIS.

Please help any input is appreciated.

THANKS.
 
Nothing

If this is exactly how the documentation reads, then ...

You do not have even an HPI recorded. You have no assessment/plan recorded (so no MDM). You have a problem focused exam of the breasts recorded.

NEW PATIENT? No bill ... there's not enough here to even qualify for a 99201

ESTABLISHED PATIENT? 99211 (only requires a chief complaint)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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