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Need help with very short chart note

  1. #1
    Everett, WA
    Default Need help with very short chart note
    Medical Coding Books
    Dr. is a specialist in migraines. Established patient. DX= 346.10. Chart notes follow:

    Pt presents for adjustment of stimulator settings. Pt. suffers from ongoing daily headaches. I recommended expanding the pulse width 3 days most distal contact point. Patient noted improvement in stimulation toleration and plans to have continuous stimulation

    That's it! It was submitted as a 99214, but obviously, that is incorrect. Shouldn't there also be a code from V53.XX as well? I'm just stumped on this one. Isn't this basically a problem focused exam and at best only be assigned 99213? No exam. MDM has stalled me. Would this be an established problem, worsening, or "stable" at this point? For "presenting problem" I have "moderate", and Management Options ????

    Can someone turn on a light for me, please? Perhaps it should be sent back asking for additional information?

    Suzanne E. Byrum CPC

  2. Default Migraine
    Looks like a V53.01 to me and 99214 looks ok for established patient...

  3. #3
    Evansville Indiana
    Default 99212
    I can't get more than a 99212 on this. It actually states notes improvement.

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