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  1. #1
    Question 99212??
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    I believe the following is a 99212? Anyone agree/disagree? thanks

    Chief Complaint
    follow up rt foot infection mom states still ***** and new spot developing

    Vital Signs
    AGE 15y5.8m
    BLOOD PRESSURE 118/80 L Arm
    WEIGHT 122.4 lb
    WEIGHT (%) 38

    History of Present Illness
    15 yo here 2 days ago for L foot abscess returns for f/u after 7 doses of keflex. Foot less sweollen, painful n ow, able to walk. Taking meds w/o problems.
    also notes has scraped chest at school yesterday lifting hood of car in auto shop. Abrasion over upper chest, No dyspnea, sob.No pain at this time

    Physical Exam
    General Appearance
    L foot/sole: 2-3 cm area with fluid at ball of foot , blister soft with blood inside, no drainage or surrounding ertythema
    Other Findings
    4 x4 superficial abrasion over sternum with some bruising, ribs and sternum not ttp. Lungs cleat to ausc
    Assessment and Plan
    L foot abscess
    chest contussion
    cont keflex as presc
    rev'd sx increasing infection
    RTC if fever, inc swelling, pain, further concerns

  2. #2
    I think this is a solid 99213.

    You have a detailed history, expanded problem focused exam (95 guidelines). The MDM could be argued to be moderate but I lean towards low.

    The foot is established so 1 point, the chest contusion I would call self limited or minor and also 1 point. You have rx management since he said to continue the abx. It could be argued that the chest contusion is a new problem with no work up which would give you moderate MDM instead of low. That would make this a 99214 but I think that would be pushing it.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

  3. Default
    I agree with the 99213. Just my two cents

  4. #4
    Definitely 99213

    You stated your chief complaint and a brief history of present illness alongside a limited examination of the affected body area. The complexity of the data was rather easy to describe and there is a low risk of complication.

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