READER QUESTIONS:
$100 Hinges on Boil Note's CPT Codes
Published on Wed May 27, 2009
Question: For the following chart note (which appears exactly as written without grammatical correction and spelling out abbreviations), I am planning on submitting 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity &Usually the presenting problem[s] are of low to moderate severity &) with 686.1 (Pyogenic granuloma) and 682.5 (Other cellulitis and abscess; buttock)? Using the CMS standard documentation worksheet, does the documentation support a level-three visit? CC: Boil on Buttock. Allergies: Ø Meds used: Augmetin Bactrim; Finished Bactrim DS 1 week ago; was better, now worsening. Sick how long? 1 month off + on. Others sick? Ø Hangnails; Ø friends or family. HPI: recurrence of abscess; Ø fever; painful when pres-sure applied; some drainage; BM and urine [...]
