# 99213 or 99214 - Patient has a comprehensive



## gelebelegirl (Sep 29, 2010)

Patient has a comprehensive history and exam.

They are an est pt, came in with nasal congestion, discharge, and cough.  
Pt dx with sinusitis.  Prescription was given.

Would you give the MDM a low or high?  

I just started on primary care work (different from Cardiology) and I am trying to determine if a sinus infection would warrant a level 4 ov.  

The sinus infection is a new dx but I was told by someone else that it would be considered a minor problem (1 point for dx).

Can anyone assist me with this?

Thanks.


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## LLovett (Sep 30, 2010)

Sinus infection w/Rx should be moderate MDM.

Why would they do a comp history and exam? Technically that would support a 5 for an established. I'm not sure that you could justify medical necessity for that level of service but that is a clinical decision.

Laura, CPC, CPMA, CEMC


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