# what level do you get?



## renifejn (Sep 10, 2008)

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


----------



## dmaec (Sep 10, 2008)

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?*


----------



## ARCPC9491 (Sep 10, 2008)

renifejn said:


> 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.
> 
> ...




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)


----------



## ARCPC9491 (Sep 10, 2008)

Donna, we have been in sync today!! LOL


----------



## dmaec (Sep 10, 2008)

LOLOL...yeah ...we have!


----------



## renifejn (Sep 11, 2008)

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


thanks


----------



## FTessaBartels (Sep 17, 2008)

*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


----------

