Wiki Code correct 99212 But!!

[simam]

Based on op note my conclusion was as follows
History=PF=Brief-Location(Leg), Quality(improved), Modifying Factors= wearing socks; ROS-Pertinent (Skin) and; PFSH=Past (Allergy)

Exam=PF-Skin

MDF=SF As ultrasound was ordered

Overall code is 99212 per Practice code but the system shows same code with History-EPF , Exam=PF and MDM is Low
Anyone can help why approaches are different with same code or I am may be wrong somewhere?

OFFICE VISIT, EST

PATIENT: LUTHER SMITH
Age: 52
This is a Commercial Payer (Follow Medicare rules)
DOS:1/1/20XX

SUBJECTIVE: The patient is seen back in clinic. He persists with a component of edema in the right leg; however, it is markedly improved. An XX/01/20XX ultrasound is reviewed. The patient has been wearing his compression socks from Medi and they have been working well. He has not had an allergic reaction to them. Overall, he is pleased. He has been continuing his pneumatic compression boot twice a day as well.

OBJECTIVE: Physical examination demonstrates no evidence for skin breakdown. He does have a component of 1 to 2+ edema but, again, this is markedly improved when compared to prior.

IMPRESSION: Doing well with his compression socks.

PLAN: Six-month followup ultrasound with clinic visit. He is to purchase another set of compression socks today.


Leif Kramer, MD
Electronically signed by LEIF KRAMER, MD 1/1/20XX

 

[twizzle]

Why are you submitting this and including a patient's name and a provider's name? Ever heard of HIPAA, redacting, confidentiality breach, and the rest?

 

[simam]

Why are you submitting this and including a patient's name and a provider's name? Ever heard of HIPAA, redacting, confidentiality breach, and the rest?

Thanks for your info. The both names are phony including other info (not real) and it is from practice problem.

 

[twizzle]

Thanks for your info. The both names are phony including other info (not real) and it is from practice problem.

Nobody, me included, would know they were phony though. Just don't use any names at all then you'll be good.

Apologies for jumping to conclusions but people have used real names in the past.

 

[ellzeycoding]

For exam.. PF (Skin) is not specific enough. You should document which areas were examined and what the findings were . Normal or abnormal.

Exam:

LLE - Normal
RLE - abnormal, edema.
(You can get 2 exam points here)


PF Skin is nebulous. Yes, I know it means 1 to 5, but list the areas examined. Did the doc only look at one leg, or both? Other areas for edema?

 

[simam]

Nobody, me included, would know they were phony though. Just don't use any names at all then you'll be good.

Apologies for jumping to conclusions but people have used real names in the past.

your intention was good -no need of apologies! It is nice of you for your comments. we are like family on this forum. we learn from each other. even i learnt from you also.