Wiki Which E&M?

[RebeccaMoney]

Established patient, new problem of bilateral DJD knees. Plan of care is ice/heat, NSAIDS,cortisone injections, and physcial therapy. Time spent not documented. I'm looking at 99213. What do you think?
Thank you,

 

[csperoni]

There is simply not enough information here to determine the level. Based on information provided, I would consider the risk moderate (cortisone injections) assuming documentation adequately describes the treatment plan.
The problem could be chronic stable (low), or chronic with exacerbation (moderate) or even possibly extensive if DJD is severe enough.
Were records reviewed? Testing ordered? Independent historian? Images interpreted? Discussion with external HCP? Data could be anywhere from none to extensive.

 

[RebeccaMoney]

Chronic condition but worsening over the last couple of days. No records reviewed nor tests ordered. One xray was ordered and read in our office. No discussion with outside physician. Patient will follow-up in our office within 4-6 weeks.

 

[RebeccaMoney]

Sorry...patient was given a cortisone injection into that knee and then told to fup in 4-6 weeks.