Pediatric Coding Alert

READER QUESTIONS :

Does Prednisone Make Dermatitis a 99214?

Question: Since prescription management involves moderate risk on the CMS standard documentation worksheet and the pediatrician in the following chart note (which appears exactly as written without grammatical correction and spelling out abbreviations) prescribes medication, I am planning on submitting the encounter with 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …Usually the presenting problem[s] are of moderate to high severity …). Is my visitl eveling correct for a note that reads: 8-year-old male; wt 114, temp 99.4, R 20; rash on face, arms, legs �" mostly all over �" X 5 days/ Nurse signature cc? poison oak -- by eye x 4-5 days, + on hands, trunk, pvt area Rx lamisil -- “anti-itch cream -- Plays in the woods. PE �" alert, [...]
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