I am having an issue with levels of E/M codes.
What would you code if this was the presenting documentation:
11 y/o, temp 98.9, wt 146, ht 58in.
Problem- pt with redness and matter x 2days of the eyes, no temp (written by nurse)
Physician doc normal- gen aspect, head, ears, nose, throat, neck, skin, heart, lungs, abdomen, etremities, hips, neuro, and developmental. He documents abnormal eyes- bilat eye redness.
Diagnoses given- conjunctivitis and URI
Treatment- vigamox and rondec DM
temp 96.8, c/o runny nose since last night, per mom temp last night but not taken (written by nurse)
MD writes normal exam as above except the abnormal is nose-mucus.
Dx is URI
Plan- rondec DM and motrin.
Please let me know what you would code for these two visits.
Its all depends on the amount of time spent with patient. I would bill at least 3rd level : 99203 for new patient visit and 99213 for established visit.
You posted question in another forum ... E/M ?
Anyway I answered there ... far too complicated to repeat here.
But definitely NOT new patient codes ... wouldn't meet standard for even 99201.
F Tessa Bartels, CPC, CEMC