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EM Coding Alert

You Be the Coder:

99213 or 99214?

Published on Tue Nov 19, 2013

Question: My ob-gyn documented the following:
Established patient CC: Vaginal Discharge HPI: Extended 4 day history of a constant vaginal discharge associated with odor. Nothing makes it better. Past Medical History Reviewed ROS 3+ systems reviewed Exam: Full pelvic exam but no further exam performed. KOH/Wet prep confirms bacterial vaginosis. Medical Decision Making: 1)
New problem diagnosed [...]
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