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Suture Removal and HPI

  1. #1
    Location
    Overland Park, KS
    Posts
    1,166
    Default Suture Removal and HPI
    Medical Coding Books
    one week ago had sutures placed at urgent care center-right forearm. Denies any problems. States he injured himself when he was working on a weekend project in his garage, cut self on piece of metal.
    -Recent antibiotic use: none
    -Associated signs and symptoms: denies any problems

    This is HPI for a recent suture removal. Maybe I am having a senior moment here, but I get location, duration, and associated signs and symptoms. Is there any other element that I am overlooking?

    Also, the provider documents social and family history here. The social history is smoking and excercise history. The family history are things like HTN, DM. Is that really clinically relevant to have a social and family history like this for a suture removal? I think not, but am I missing the boat here?

    TIA.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
    Default
    Context: injured himself when he was working on a weekend project in his garage, cut self on piece of metal.

    Laura, CPC, CPMA, CEMC

  3. #3
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Ah...context! I missed that one. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default SO you're trying for 99214 or 99215?
    So you're trying to see if you have documentation for 99214 or 99215?

    Seems excessive to remove sutures.

    If you want to support 99214 you only need ONE element of past medical, family or social history. (Wondering if you have an electronic record and everything is carried forward automatically.)

    Just my thoughts.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    I don't think this meets the criteria for a 99214 in anyway. This was coded as 99213, but the MDM was only SF, so it is a 99212 at best.

    I totally agree that the family and social history is unecessary here. My providers just don't understand medical necessity. They think pharyngitis warrants a comprehensive exam!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

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