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Wiki What Level would you choose???? Thanks

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HeidiLynn

Networker
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Location
Dexter, OR
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Pt presents to clinic today regarding pain and discomfort in her right foot. She relates that it feels about the same. She underwent an MRI scan which showed some arthrosis through her midfoot joints but there is significant tenosynovitis in the area of the tibialis anterior tendon.

IMPRESSION
Anterior tibial tendinitis.

PLAN
At this point in time we will send her to physical therapy for approximately 8 visits. She will undergo this and follow back with me for recheck in 8 weeks.
 
Can you break down how you got that? I am having a hard time getting anything past a 99212 with no exam or ROS. It looks like an established problem, stable to me. It is hard to tell from what is written, but the fact that the patient says it is the same and already had an MRI leads me to established problem.
 
History is problem focused (without ROS) and MDM straight forward (with stable established problem and one MRI review and physical therapy that accounts to low risk). This is clear cut 99212.
 
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