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Thread: E/M level question

  1. #1

    Default E/M level question

    AAPC: Back to School
    Provider wants to bill a 99203. I can only get a 99202. Needs some input on this visit please. Thank you!

    CC: vertigo and pressure in ears.

    History of Present Illness:
    Patient presents with vertigo for the past 2-3 weeks and seems to be getting worse. States she gets spinning sensation when she rolls over in bed and with other position changes. No headache or vision changes. Had similar problem a year ago and had wax cleaned out of her ears which seemed to help. She reports that her ears feel "full" but not really plugged. No recent illness but does get a lot of sinus drainage and congestion from his allergies. Uses nasonex. Has some ringing in the ears but that is chronic and unchanged. No hearing loss. No ear pain or fever.

    Risk Factors:

    Vital Signs:

    Patient Profile: Years Old
    Height: 76 inches
    Weight: 239.0 pounds
    BMI: 29.20
    BSA: 2.39
    Temp: 96.7 degrees F tympanic
    Pulse rate: 68 / minute
    Pulse rhythm: regular
    BP sitting: 142 / 80 (left arm)
    Cuff size: regular

    Vitals Entered By:

    Physical Exam

    well developed, well nourished, in no acute distress.
    no sinus tenderness
    right tm is normal and canal is clear; left tm is slightly retracted and injected; canal clear
    pharynx benign
    Cervical Nodes:
    no significant adenopathy.

    Impression & Recommendations:

    Problem # 1: BENIGN POSITIONAL VERTIGO (ICD-386.11)

    His updated medication list for this problem includes:
    Meclizine Hcl 25 Mg Tabs (Meclizine hcl) ..... One po q6 hours prn

    she was reassured this is not dangerous but can be very bothersome; she can use the meclizine prn; continue the nasonexas she probably has some component of eustacian tube dysfunction; she is traveling through this area and will be heading back to Montana in 2-3 weeks; if her problems persist, advised she should see his primary physician to consider PT or referral to ENT; if she develops vomiting, double visio or other neurologic symptoms she should be rechecked

    Medications Added to Medication List This Visit:
    1) Aspirin 81 Mg Tabs (Aspirin) .... 2 po qd
    2) Multivitamins Tabs (Multiple vitamin) .... 1 po qd
    3) Nasonex 50 Mcg/act Susp (Mometasone furoate) .... 1-2 sprays per nostril qd
    4) Aleve Caps (Naproxen sodium caps) .... Prn
    5) Meclizine Hcl 25 Mg Tabs (Meclizine hcl) .... One po q6 hours prn

    MECLIZINE HCL 25 MG TABS (MECLIZINE HCL) one po q6 hours prn #40 x 0
    Entered and Authorized by: Method used:

  2. #2
    Join Date
    Apr 2007
    Green Bay, WI


    I also only get a 99202 for this visit as well. This is what I get.....Exp Prob Foc HISTORY (hpi=extended, ros=prob pert, pfsh=n/a), Exp Prob Foc EXAM (limited exam of affected body area & other related systems), LOW Medical Decision Making (limited dxs/management options, no data reviewed, moderate risk (due to rx)).

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