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what level do you get?

  1. Default what level do you get?
    Medical Coding Books
    patient w/ tics. Hair twisting is a tic still occuring. Other tics gone. Grades good at school Otherwise no concerns upone today's visit. Mother wondering if Clondine can be weaned.

    Mental status, cranial nerves, motor, sensory, cerebellar, gait, and reflex exam all normal for age. The remainder of the physicial exam is unremarkable.

    Impression: tics,stable

    REc consider weaning clonidine, but would wait until fall. wean by 1/2 tab over 2 wks

  2. #2
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    renifejn
    I get a 99212
    History = Problem Focused
    EXAM = Expanded Problem Focused
    MDM = Straightforward

    {that's my opinion on the posted matter}

    what did you get?
    Donna, CPC, CPC-H

  3. #3
    Default
    Quote Originally Posted by renifejn View Post
    patient w/ tics. Hair twisting is a tic still occuring. Other tics gone. Grades good at school Otherwise no concerns upone today's visit. Mother wondering if Clondine can be weaned.

    Mental status, cranial nerves, motor, sensory, cerebellar, gait, and reflex exam all normal for age. The remainder of the physicial exam is unremarkable.

    Impression: tics,stable

    REc consider weaning clonidine, but would wait until fall. wean by 1/2 tab over 2 wks

    CC: Patient w/ tics
    HPI: Hair twisting = Context & Clonidine = Modifying Factor 2 HPI Elements
    ROS: None Documented
    PFSH: Grades good at school = Social - 1/3 PFSH
    History: Problem Focused (1 ROS would have given him/her Expanded Problem Focused)

    Exam: Expanded Problem Focused for both 1995 and 1997 Guidelines

    MDM:
    Established Problem, Stable 1 Point
    0 Data Points
    Risk could be either One Stable Chronic Illness (Low). Rx Drug Management (Moderate) shouldn't be used because he is not changing the dose at this time. Even if he were, the Moderate Risk wouldn't raise the overall level of MDM because of the minimal problem points and no data points.

    Overall MDM: Minimal/Straightforward

    Overall Level = 99212
    Hx: PF, Ex: EPF, MDM: Minimal/Straightfoward (2/3 for Established Patients)
    Last edited by ARCPC9491; 09-10-2008 at 02:37 PM. Reason: misread original note ... made changes accordingly

  4. #4
    Default
    Donna, we have been in sync today!! LOL

  5. #5
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    LOLOL...yeah ...we have!
    Donna, CPC, CPC-H

  6. Default
    That's what I got too....though the exam was getting to me....it was one of those days....


    thanks

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default History - ROS
    I get Expanded Problem focused history.
    For Expanded problem focused you only need 1-3 HPI element; you already have "hair twisting" and "Clondine" ... so I think you could count "Other tics gone" as ROS.

    You have an Expanded Problem focused exam

    So I get 99213. (It's weak, but there it is.)

    F Tessa Bartels, CPC, CPC-E/M

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