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Level e/m opinions please

  1. #1
    Question Level e/m opinions please
    Medical Coding Books
    f/u skin issues spot on back uses

    would like referral to derm

    also still has lump R lower chest. - needs to rt spirito for ? of surgical removal.

    tore acl- never had it repaired. never f/u with ortho.

    Vital Signs
    AGE 21y11.6m
    WEIGHT 136 lb
    BMI 21.7

    Interval History
    Illness/Injury since last visit? N
    Specialty appointment since last visit? N
    Hospitalization, Surgery, ER, Urgent visit since last visit? N

    Social History
    Pets in environment? N
    Firearms in environment? N
    TB Risk Status? Low
    Education Attends school
    Financial instability? N

    pt immigrated to uS at age 8 in 1997 , needs ppd for college

    Physical Exam
    General Appearance

    ‎WDWN, NAD


    tinea versoicolor over entire torso, back, hypopigmented dry and scaly. 4 cm soft mass R lower chest.

    Assessment and Plan

    R acl needs f/u

    tinea versicolor

    mass R lower chest


    ortho f/u

    derm consult

    surgical f/u

    Call/Return if worse or not better in:

    RTO if worse sxs, new sxs or not improving.

    Patient came in for his skin issues but then dr referred him to f/u on 2 other issues that were previously addressed that patient never saw specialist for. I believe this is a 99212. Dr wants to charge a 99214. any thoughts?? thanks

  2. Default
    Based on the documentation above and 95 guidelines......I would code this report as a 99213. The HPI is lacking so you would need to pull something for ROS, making the History, expanded prob focused,
    the Exam is expanded problem focused and the MDM is need 2 out of three so I would code this as a 99213.

    Let me know if you agree,

    Mary Lou Saunders, CPC

  3. #3
    Milwaukee WI
    Default 99213
    I agree with Mary Lou. 99213. You have expanded problem focused history, and an expanded problem focused exam.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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