Wiki 99212??

[HBULLOCK]

I believe the following is a 99212? Anyone agree/disagree? thanks

Chief Complaint
follow up rt foot infection mom states still ***** and new spot developing

Vital Signs
AGE 15y5.8m
TEMPERATURE 96.8 F
BLOOD PRESSURE 118/80 L Arm
WEIGHT 122.4 lb
WEIGHT (%) 38

History of Present Illness
15 yo here 2 days ago for L foot abscess returns for f/u after 7 doses of keflex. Foot less sweollen, painful n ow, able to walk. Taking meds w/o problems.
also notes has scraped chest at school yesterday lifting hood of car in auto shop. Abrasion over upper chest, No dyspnea, sob.No pain at this time

Physical Exam
General Appearance
WDWN, NAD
Skin
L foot/sole: 2-3 cm area with fluid at ball of foot , blister soft with blood inside, no drainage or surrounding ertythema
Other Findings
4 x4 superficial abrasion over sternum with some bruising, ribs and sternum not ttp. Lungs cleat to ausc
Assessment and Plan
Assesment
L foot abscess
chest contussion
Plan:
cont keflex as presc
rev'd sx increasing infection
RTC if fever, inc swelling, pain, further concerns

 

[LLovett]

I think this is a solid 99213.

You have a detailed history, expanded problem focused exam (95 guidelines). The MDM could be argued to be moderate but I lean towards low.

The foot is established so 1 point, the chest contusion I would call self limited or minor and also 1 point. You have rx management since he said to continue the abx. It could be argued that the chest contusion is a new problem with no work up which would give you moderate MDM instead of low. That would make this a 99214 but I think that would be pushing it.

Just my take on it,

Laura, CPC, CPMA, CEMC

 

[eadun2000]

I agree with the 99213. Just my two cents

 

[nelsong5]

Definitely 99213

You stated your chief complaint and a brief history of present illness alongside a limited examination of the affected body area. The complexity of the data was rather easy to describe and there is a low risk of complication.