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Is this a a 99212

  1. #1
    Default Is this a a 99212
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    Would you squeeze out a level 99212 (established). If your note read.

    Chief complaint: Tuggin and pulling at ear

    HPI: Inflammation of the ear, pass 2 days.

    Plantitis media, Augmentin 7 to 10days.

  2. #2
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    Yes, for est. pt you need to meet 2 out of 3 (hx, pe, mdm).
    Even though the PE is not documented, but there is a CC, the hx level is PF (brief HPI, no ROS, no PFSH). The MDM is SF, because of 1 self-limited problem with Rx drug management.
    Even if you want to consider the "otitis media" as a new problem, still, the LOS would be 99212, because your hx level is SF and there is no PE.
    Hope this will help
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  3. Default
    Quote Originally Posted by daniel View Post
    Would you squeeze out a level 99212 (established). If your note read.

    Chief complaint: Tuggin and pulling at ear

    HPI: Inflammation of the ear, pass 2 days.

    Plantitis media, Augmentin 7 to 10days.
    You have a brief hx and moderate mdm, you only need 2 of 3 elements to meet the 99212 level.

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