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Stuck between a 2&3. Opinions please?!

  1. Default Stuck between a 2&3. Opinions please?!
    Medical Coding Books
    Diagnosis: JDM
    Other diagnoses: none
    Social History (grade, PE, activities, school days missed): Sr in HS, good grades, ful pe, badmitton, tennis, golf, missed 4 days due to pneumonia


    SPECIFIC COMPLAINTS/PROBLEMS ILLNESS:
    none


    NEW FAMILY HISTORY:
    none


    REVIEW OF SYSTEMS:


    SKIN: Normal
    EYES: Normal
    EARS: Normal
    NOSE: Normal
    MOUTH: Normal
    RESP: Normal
    CARDIO: Normal
    GI: Normal
    MUSCULOSKELETAL: Normal
    NEURO: Normal
    GU: Normal
    Nighttime Urination: No
    MENSES: Yes Time Between Periods 28 days
    ENDOCRINE: Normal
    PSYCH: Normal
    LYMPHATIC: Normal


    Eye Exam: Yes Date of Last Eye Exam 1/09
    General appetite: good
    Calcium intake in diet? Yes Servings per day? 3
    Sunscreen use? Yes SPF # 45
    Pain: No
    Stiffness: None
    Presence of Infection: No
    Infectious episodes since last visit: Yes Number of episodes: 2 Location of infection(s): Pneumonia-treated with a Z-Pak
    Functional Status: Normal function (able to attend school, keep up with friends)


    PHYSICAL EXAM:
    Blood pressure 121/77, pulse 80, resp. rate 20, height 151.2 cm, weight 40 kg.
    BSA: Body surface area is 1.37 meters squared.
    GENERAL APPEARANCE: Normal
    SKIN: ABNORMAL: Vitiligo on back
    HEAD: Normal
    EYES: Normal
    EARS, NOSE, THROAT, MOUTH: Normal
    NECK: Normal
    RESPIRATORY: Normal
    CARDIOVASCULAR: Normal
    ABDOMINAL: Normal
    GENITOURINARY: Tanner Stage: 3
    MUSCULOSKELETAL: Normal
    NEUROLOGIC: Normal
    PSYCHIATRIC: Normal


    Skin Involvement: Absent or resolved completely
    Distribution: None
    Neck Flexor Weakness: No Grade: 5
    Difficulty clearing scapula (abdominal weakness) No
    Can do sit-up with: 3=behind head
    Upper prox. muscle weakness 5 No
    Lower prox. muscle weakness 5 No
    Gower's sign: Unassisted
    Abnormal gait No
    Difficulty swallowing No
    Nasal speech No
    Spine Expansion: 15-22cm
    Vasculitis: No
    Severe Vasculitis: No
    Gotrons' Papules: Absent
    Calcification: Absent
    Peripheral fat atrophy: Absent
    Acanthosis Nigricans: Absent
    Raynaud's: Absent
    Loss of ROM No
    Status of JDM: No Rash or Weakness


    Meds: On Immunosuppressive therapy


    VISIT IMPRESSION:
    JDM-stable exam, no active arthritis


    VISIT PLAN:
    Lab evaluation today

  2. #2
    Default
    Is this an established patient visit? Looks like it. In that case I can see how you are in between. You need two of three and based on history and exam you would get a 99213. However, MDM should be a driving factor - and the MDM really is straight forward in my opinion (which supports the 99212). How much of the history and exam was truly medically necessary? Every so often it is possible that medical necessity is higher than the medical decision making and it would be fair to base the code on history and exam. If a lot of the information is documented because the template prompted for it, it might be overdocumented. Do you have similar cases to compare the note to and figure out if all the history and exam was needed to provided appropriate care?

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