# ED E/M Level Code 99281 or 99283?



## naena001 (Mar 7, 2014)

Greetings All,

I am wondering what level E/M code you would use for this case?


CHIEF COMPLAINT: Right eye pain. 

SUBJECTIVE: This is a pleasant, 45-year-old male with a remote history of corneal ulcers from his contacts. He presents with a 2-day history of right eye sensitivity, photophobia, a little bit of mattering this morning. He does wear contacts. He threw them away yesterday. He said he had 
them in for a month-and-a-half. It feels "grainy." 

PAST MEDICAL HISTORY: As above. He is on Toprol and Lotensin presumably for hypertension. 

REVIEW OF SYSTEMS: As above. 

PHYSICAL EXAMINATION: Vitals are stable. Visual acuity of 20/50 OD 20/25 OS. On examination, nothing is seen grossly. The eyelids are reverted and nothing was seen. After tetracaine analgesia and fluorescent staining upon slit visualization, there is indeed uptake of a fluorescent between 2 and 3 o'clock right at the edge of the cornea. 

ASSESSMENT: Corneal abrasion OD due to contact lens 

PLAN: I told him no more contacts until he sees his physician. I did place some cyclogel and wrote a prescription for some gentamicin drops. I did not patch at this point but wanted him to see his eye doctor.


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## OCD_coder (Mar 8, 2014)

Expanded problem focused Hx and exam and Moderate MDM.  The patient has a new problem with an acute uncomplicated injury of the cornea.  The eye exam complexity using stain is more than straightforward, it supports the acuity level as well and prescription for eye drops.  Think of the eye exam equal to an x-ray or lab diagnostic as far as equivalent to the work needed to determine a treatment plan.

99283


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