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Help! Em level

  1. #1
    Question Help! Em level
    Medical Coding Books
    ESTABLISHED PT

    EPF HISTORY
    DETAILED PE

    RIGHT HAND SIGNIFICANT PAIN, LEFT HAND MINIMAL. TESTING CONCLUDES LEFT HAND CTS BUT NOT IN RIGHT.
    PLAN -Discussed prognosis of carpal tunnel syndrome.

    -Discussed referral to physical therapy for her hand symptoms.

    -Discussed referral to hand surgery.

    ANY THOUGHTS GREATLY APPRECIATED!

  2. #2
    Location
    Kansas City, MO
    Posts
    434
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    Pt has CTS, seems like a new problem. The note says "discussed" options of therapy and surgery, but I don't know whether it was actually ordered on not. based on what is there I would go with a 99213.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

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