Wiki 99213 or 99214 - Patient has a comprehensive

[gelebelegirl]

Patient has a comprehensive history and exam.

They are an est pt, came in with nasal congestion, discharge, and cough.
Pt dx with sinusitis. Prescription was given.

Would you give the MDM a low or high?

I just started on primary care work (different from Cardiology) and I am trying to determine if a sinus infection would warrant a level 4 ov.

The sinus infection is a new dx but I was told by someone else that it would be considered a minor problem (1 point for dx).

Can anyone assist me with this?

Thanks.

 

[LLovett]

Sinus infection w/Rx should be moderate MDM.

Why would they do a comp history and exam? Technically that would support a 5 for an established. I'm not sure that you could justify medical necessity for that level of service but that is a clinical decision.

Laura, CPC, CPMA, CEMC