# 99203 or 99204



## cwilson3333 (May 15, 2014)

Would like to have someone audit this exam on a new patient? 

Patient:  Mrs. Ortho
DOS:      5-1-2014

CC: Left foot pain

HPI: The patient is a 76-year old female who has had ongoing pain in the left foot.  She has a history of plantar fasciitis. She has some low back pain that also radiates down the leg. The foot has been ongoing for 6-8 months. It is the top of the foot. She has had no specific trauma or previous history of this problem. Walking is really bad. There is no night pain. Sitting is okay. She had plantar fasciitis 14 years ago that got better on its own. She has a history of a bone growth or bone tumor that was removed in 2000. She says this interferes with daily activities.

ROS: 
Musculosketal:  Foot pain. Back pain. Radiation of pain
Cardiovascular: HTN. Heart Disease with silent MI. High cholesterol
Vascular: Easy Bruising
GI: Reflux
General: Menopause

All other systems are negative.

Medications, allergies, PMH, PSH, SH AND FH are listed in chart and have been reviewed.

VITALS: BP 123/52. PULSE 52. TEMP 97.7. H: 5'1". W: 165 LBS.

PHYSICAL EXAM:
General Appearance: WDWN female in no acute distress

Musculoskletal: Exam of left foot, she is tender over the LisFranc region, primarily at the TMJ of second/third rays and a little over the navicular posterior tibial tendon. She has a flatfoot alignment. She has a decrease in subtalar motion of her left foot.

Neurological: Okay. She has mild swelling.

ORDERS: Xrays from hospital and I reviewed those. The show midfoot arthritis.

ASSESSMENT: Midfoot arthritis. Ankle pain

PLAN: The plan is to wear the inserts and a referral to Dr Foot Specialty. She can follow up here as needed.

Dr. Ortho, MD

99203
  or 
99204

DX: 715.17, 719.47


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## MikeEnos (May 15, 2014)

Well, a 99204 requires a *Comprehensive exam*.  Since you only have three systems there I would say you would be VERY generous to even call this a 99203.  I would lean more towards calling that exam expanded problem focused, limiting this to a 99202.


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## dtricia (May 16, 2014)

The exam is EXP so overall this is 99202, no where near a 99204. Medical Decision Making would not be there either.

Tricia Didier, RHIT, CPC, CCS-P, CHONC


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