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Thread: Level e/m opinions please

  1. #1
    Join Date
    Apr 2007

    Question Level e/m opinions please

    AAPC: Back to School
    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. #2


    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 moderate..........you 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
    Join Date
    Apr 2007
    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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