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99214 vs 99213 - Impression & Recommendations

  1. Default 99214 vs 99213 - Impression & Recommendations
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    Providers wanted to bill a 99214. We feel its a 99213.

    Primary Provider:
    CC: f/u wrist.

    History of Present Illness:
    He presents for follow-up of his wrist. He states it "feels fine". No pain or swelling.

    He also had his labs done today and those are reviewed with him. His renal function is stable. His low platelets are stable and his hemoglobin is actually up compared to his baseline. His cholesterol is excellent.

    Past Medical History:
    Reviewed history from 09/04/2009 and no changes required:

    Atrial Fibrillation
    -- Bladder bleed on coumadin
    Basal Cell CA, L cheeck, removed
    CHF -- EF 35%, non ischemic on P thall 6/07
    -- declines further cardiac evaluation or AICD
    Severe Mitral Regurgitation
    Mild - Moderate Aortic Insufficiency and Tricuspid Regurgitation
    Moderate Pulmonary HTN (PA pressure = 56)

    Past Surgical History:
    Reviewed history from 02/04/2011 and no changes required:

    TURP 2005, 2002
    Inguinal Hernia Repair
    R LE trauma due to WWII injury

    Family History:
    Reviewed history from 06/12/2007 and no changes required:


    Social History:
    Reviewed history from 04/10/2007 and no changes required:

    Lives alone, does not smoke or use ETOH

    Risk Factors:

    Review of Systems

    Complains of fatigue.
    Thinks he is a little more tired than he should be

    Denies chest pain or discomfort.

    See HPI

    Vital Signs:

    Patient Profile: Years Old Male
    Height: 68 inches
    Weight: 152.0 pounds
    BMI: 23.20
    BSA: 1.82
    Temp: 96.5 degrees F tympanic
    Pulse rate: 48 / minute
    Pulse rhythm: regular
    BP sitting: 118 / 58 (left arm)
    Cuff size: regular

    Vitals Entered By:
    Physical Exam

    well developed, well nourished, in no acute distress.
    No bruising or tenderness in his right wrist. No swelling. Extensive DJD

    Test Management:

    Tests Reviewed:
    BUN: 37 (01/26/2011)
    Creatinine: 1.8 (01/26/2011)
    Sodium: 140 (01/26/2011)
    Potassium: 4.9 (01/26/2011)
    Chloride: 106 (01/26/2011)
    CALCIUM: 9.2 (01/26/2011)
    ANIONGAP: 15 (01/26/2011)
    CO2 Total: 24.3 (01/26/2011)
    GLUCOSE SER: 98 (01/26/2011)
    CBC w/ diff:
    HGB: 11.4 (01/26/2011)
    HCT: 35.8 (01/26/2011)
    RBC: 3.79 M/UL (01/26/2011)
    WBC: 8.2 (01/26/2011)

    Impression & Recommendations:

    Problem # 1: WRIST PAIN, RIGHT (ICD-719.43)
    Sprain has resolved. No further need for brace.

    Problem # 2: ANEMIA NOS (ICD-285.9)
    Counts have actually improved. No changes or further investigation at this point

    Basic metabolic panel is stable.

    His updated medication list for this problem includes:
    Aspirin 81 Mg Tbec (Aspirin) ..... 1 po qd
    Triamterene-hctz 75-50 Mg Tabs (Triamterene-hctz) ..... 1/2 tab daily
    Lisinopril 10 Mg Tabs (Lisinopril) ..... 1 tab po q.d.

    Problem # 4: DYSLIPIDEMIA (ICD-272.9)
    Exceptional lipid profile today

  2. Default
    I can where this would be a 99214 with a detailed history due to an extended ROS, an expanded problem focused exam and medical decision making of moderate complexity due to 3 stable chronic conditions with medicine management/review.

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