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99213 or 99214 - Patient has a comprehensive

  1. Default 99213 or 99214 - Patient has a comprehensive
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    Patient has a comprehensive history and exam.

    They are an est pt, came in with nasal congestion, discharge, and cough.
    Pt dx with sinusitis. Prescription was given.

    Would you give the MDM a low or high?

    I just started on primary care work (different from Cardiology) and I am trying to determine if a sinus infection would warrant a level 4 ov.

    The sinus infection is a new dx but I was told by someone else that it would be considered a minor problem (1 point for dx).

    Can anyone assist me with this?


  2. #2
    Sinus infection w/Rx should be moderate MDM.

    Why would they do a comp history and exam? Technically that would support a 5 for an established. I'm not sure that you could justify medical necessity for that level of service but that is a clinical decision.

    Laura, CPC, CPMA, CEMC

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