Wiki Suture Removal and HPI

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dballard2004

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one week ago had sutures placed at urgent care center-right forearm. Denies any problems. States he injured himself when he was working on a weekend project in his garage, cut self on piece of metal.
-Recent antibiotic use: none
-Associated signs and symptoms: denies any problems

This is HPI for a recent suture removal. Maybe I am having a senior moment here, but I get location, duration, and associated signs and symptoms. Is there any other element that I am overlooking?

Also, the provider documents social and family history here. The social history is smoking and excercise history. The family history are things like HTN, DM. Is that really clinically relevant to have a social and family history like this for a suture removal? I think not, but am I missing the boat here?

TIA.
 
Context: injured himself when he was working on a weekend project in his garage, cut self on piece of metal.

Laura, CPC, CPMA, CEMC
 
SO you're trying for 99214 or 99215?

So you're trying to see if you have documentation for 99214 or 99215?

Seems excessive to remove sutures.

If you want to support 99214 you only need ONE element of past medical, family or social history. (Wondering if you have an electronic record and everything is carried forward automatically.)

Just my thoughts.

F Tessa Bartels, CPC, CEMC
 
I don't think this meets the criteria for a 99214 in anyway. This was coded as 99213, but the MDM was only SF, so it is a 99212 at best.

I totally agree that the family and social history is unecessary here. My providers just don't understand medical necessity. They think pharyngitis warrants a comprehensive exam!
 
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