what level do you get?

renifejn

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patient w/ tics. Hair twisting is a tic still occuring. Other tics gone. Grades good at school Otherwise no concerns upone today's visit. Mother wondering if Clondine can be weaned.

Mental status, cranial nerves, motor, sensory, cerebellar, gait, and reflex exam all normal for age. The remainder of the physicial exam is unremarkable.

Impression: tics,stable

REc consider weaning clonidine, but would wait until fall. wean by 1/2 tab over 2 wks
 

dmaec

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renifejn
I get a 99212
History = Problem Focused
EXAM = Expanded Problem Focused
MDM = Straightforward

{that's my opinion on the posted matter}

:) what did you get?
 

ARCPC9491

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patient w/ tics. Hair twisting is a tic still occuring. Other tics gone. Grades good at school Otherwise no concerns upone today's visit. Mother wondering if Clondine can be weaned.

Mental status, cranial nerves, motor, sensory, cerebellar, gait, and reflex exam all normal for age. The remainder of the physicial exam is unremarkable.

Impression: tics,stable

REc consider weaning clonidine, but would wait until fall. wean by 1/2 tab over 2 wks

CC: Patient w/ tics
HPI: Hair twisting = Context & Clonidine = Modifying Factor 2 HPI Elements
ROS: None Documented
PFSH: Grades good at school = Social - 1/3 PFSH
History: Problem Focused (1 ROS would have given him/her Expanded Problem Focused)

Exam: Expanded Problem Focused for both 1995 and 1997 Guidelines

MDM:
Established Problem, Stable 1 Point
0 Data Points
Risk could be either One Stable Chronic Illness (Low). Rx Drug Management (Moderate) shouldn't be used because he is not changing the dose at this time. Even if he were, the Moderate Risk wouldn't raise the overall level of MDM because of the minimal problem points and no data points.

Overall MDM: Minimal/Straightforward

Overall Level = 99212
Hx: PF, Ex: EPF, MDM: Minimal/Straightfoward (2/3 for Established Patients)
 
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renifejn

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That's what I got too....though the exam was getting to me....it was one of those days....


thanks
 
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History - ROS

I get Expanded Problem focused history.
For Expanded problem focused you only need 1-3 HPI element; you already have "hair twisting" and "Clondine" ... so I think you could count "Other tics gone" as ROS.

You have an Expanded Problem focused exam

So I get 99213. (It's weak, but there it is.)

F Tessa Bartels, CPC, CPC-E/M
 
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