mrolf
Guest
Our family physicians do pre-op physicals for surgery. They always want to bill a 99214. However, I question whether they should really be a 99214 or a 99213 according to their documentation. For example:
Chief complaint: lump on the left leg, very painful.
HPI: 49 yr old man who hurt his left anterior leg when he stepped off a truck at his job. He developed a left anterior compartment fascial herniation. He is scheduled to undergo a left leg closed anterior compartment fasciotomy. This will be done on 8/05/10 by Dr. Surgeon. I was asked to see him for preoperative clearance.
Past medical illnesses: none
Current medications: none
Allergies: none
Previous surgery: He had skin grafting of rt lower extremity secondary to a car accident.
Family history: His mother has diabetes, grandfather died of a stroke in his 80's.
13 review if systems: is essentially negative.
Exam: Temp : 98.2, Pulse:68, Respirations: 20, B/P: 128/82, Wt.209
Heent: TM's intact, no fluid,no discharge. Posterior oral pharynx-no erythma, no edema or exudate. Mucous membranes are moist.
Neck: SUpple. Lung: clear to auscultation. Heart: regular rate & rhythm.
Abdomen: soft, neontender, good bowel sounds.
Extremities: he does have a bump on the left anterior shin, very tender to palpation. Neurological: Alert, orientated. Cranial nerves II throught XII are intact.
Assessment: Left anterior compartment fascial hernia.
Plan: He is an acceptable surgical candidate.
Any information I can give to the physicians would be most appreciative.
Thanks.
Chief complaint: lump on the left leg, very painful.
HPI: 49 yr old man who hurt his left anterior leg when he stepped off a truck at his job. He developed a left anterior compartment fascial herniation. He is scheduled to undergo a left leg closed anterior compartment fasciotomy. This will be done on 8/05/10 by Dr. Surgeon. I was asked to see him for preoperative clearance.
Past medical illnesses: none
Current medications: none
Allergies: none
Previous surgery: He had skin grafting of rt lower extremity secondary to a car accident.
Family history: His mother has diabetes, grandfather died of a stroke in his 80's.
13 review if systems: is essentially negative.
Exam: Temp : 98.2, Pulse:68, Respirations: 20, B/P: 128/82, Wt.209
Heent: TM's intact, no fluid,no discharge. Posterior oral pharynx-no erythma, no edema or exudate. Mucous membranes are moist.
Neck: SUpple. Lung: clear to auscultation. Heart: regular rate & rhythm.
Abdomen: soft, neontender, good bowel sounds.
Extremities: he does have a bump on the left anterior shin, very tender to palpation. Neurological: Alert, orientated. Cranial nerves II throught XII are intact.
Assessment: Left anterior compartment fascial hernia.
Plan: He is an acceptable surgical candidate.
Any information I can give to the physicians would be most appreciative.
Thanks.