# 99213??



## HBULLOCK (Sep 21, 2010)

I WOULD LIKE TO GET A SECOND OPINION ON THIS DOCUMENTATION PLEASE:

Chief Complaint 
rt index finger red and swollen, no fever. started as a small pimple 5 days ago. got much worse in past 24 hours.pt had mrsa of chin july,2009. 
family-sib had mrsa infection june 2010 

Vital Signs 
AGE 18y4.2m
TEMPERATURE 97.7 F
BLOOD PRESSURE 118/68 L Arm
WEIGHT 173.4 lb
WEIGHT (%) 94

Interval History 
Illness/Injury since last visit? N
Specialty appointment since last visit? N
Hospitalization, Surgery, ER, Urgent visit since last visit? N
Other 
had MRSA july 2009.of chin and was hosp at tufts. 
Social History 
Household changes? N
Smokers in environment? Y
patient
Pets in environment? Y
1 cat
TB Risk Status? Low
Education Attends school
umass lowell
Physical Exam 
General Appearance 
WDWN, NAD
Skin 
abcess R index finger with sl purulent drainage between first and 2nd mp jts. . decr rom. swelling , erythema + . no axillary glands. 
Assessment and Plan 
Assesment 
abscess R index finger-? mrsa
Plan: 
bactrim ds bid
warm soaks, elevate. 
rto tomorrow.if not improving will admit for iv therapy.   THANKS!!


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## Orthocoderpgu (Sep 22, 2010)

*I think you have a 99213*

HPI   Four
ROS  One   (EFP HX)

Exam
97-PF  Four bullets
95-EPF (Three Systems)

Three Problem points, no date points, low risk = Low MDM

Even if your exam were PF it would still meet 2/3 for a 99213.


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## jdibble (Sep 22, 2010)

I think this is a 99214 -

HPI -4 = Detailed
ROS -2 (skin and constitutional) = Detailed
PFSH -2

Exam - 95 guidelines - 3 areas = EPF

MDM - would be Moderate - the doctor issued an RX so risk is moderate , Problem would be 3 for new problem and no data points.

Established patient - 2/3 elements would be Detailed History, EPF Exam and Moderate Complexity for MDM = 99214


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