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  1. #11
    Duluth, Minnesota
    Medical Coding Books
    I agree with katmryn78 (Laura) on this one. It's a "follow-up", and yes - the child has had 3 infections since the tubes were placed, however, it doesn't appear to be the case at "THIS" office visit. So that info pretty much falls to "past medical history". Not to mention, his TM's appear normal on this visit. Per documentation.

    agreed - need more info for the MDM..

    again, I agree with katmryn78 (Laura) on her assessment of this visit.
    Donna, CPC, CPC-H

  2. #12
    It sounds like to me the patient still has OM - doing "well" on meds but still blockage, still drainage all signs/sx of OM. or maybe it's from the functionality of the tubes.... I need the a/p. are these short term tubes? maybe he's considering replacing w/ long term? Post the rest of the note if you could... too many if's... this is why I just love E/M.....

  3. #13
    Milwaukee WI
    Default Resolved vs worsening
    I'm not convinced that this visit is for a worsening problem, since the poster began by saying this was for OM resolved and the Chief complaint is just F/U ears. It's possible the doctor is just being thorough in his chronology by referencing the 3 infections.

    But everything else that AR noted, I agree with. The Hx and Exam (per 1995) guidelines get me to a 99214. (By the way , I notice that for PMFSH the doctor writes "reviewed -no changes required" so I'm assuming there is a patient questionaire in the chart somewhere that would have this in detail.)

    Still, just as AR mentioned, I'd like to see the rest of the note. If it really is a resolved problem and there's no further work-up I might be less inclined to go with the 99214. But it is definitely at the very least a 99213 visit.

    F Tessa Bartels, CPC, CEMC

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