Love Coding!
Expert
Our office uses the SOAP format by dictation.
Established pt...
This pt has returned to our office for a severe rash on the face that comes and goes, pt feels that this has been going on for 3 months. Was prescribed a topical cream with little improvement. The patient wants to have this looked at. There is no past/family history of skin cancer. This patient works at a nursery and is outside the majority of the time. The review of systems are all negative and noted in the chart.
Subjective - HPI (have met 5 components, severe, face, comes and goes, 3 months and topical cream used) severity, location, timing, duration and modifing factor
Have met all three elements of the HPI 99214
4 - History of present illness
3- Past, Family and Social history
9 - review of systems (based on our office guidelines)
The following areas have been examined for a skin rash, head, neck, abdomen, back, upper and lower extremities. Other than the head none of these areas have been affected.
Objective - Exam 8 body areas 99214
1. Rash of the face. Have instructed to use sunscreen and return in two weeks if no improvement.
Assessment/Plan - MDM low (due to over the counter treatment) 99213
What would this level be? A 99213 or a 99214? I know that with an established office visit you can code by history and exam or by history and medical decision making.
Would this be accurate, if the MDM is moderate 99214, exam is 2-4 body areas 99213 and the HPI is at a level 99214 could I code it a 99214?
On the flip side of that if the MDM is low 99213, exam was 5-7 body areas 99214 and HPI is 99214 could I code a 99214?
Any help out there would be greatly appreciated!
Denise
Established pt...
This pt has returned to our office for a severe rash on the face that comes and goes, pt feels that this has been going on for 3 months. Was prescribed a topical cream with little improvement. The patient wants to have this looked at. There is no past/family history of skin cancer. This patient works at a nursery and is outside the majority of the time. The review of systems are all negative and noted in the chart.
Subjective - HPI (have met 5 components, severe, face, comes and goes, 3 months and topical cream used) severity, location, timing, duration and modifing factor
Have met all three elements of the HPI 99214
4 - History of present illness
3- Past, Family and Social history
9 - review of systems (based on our office guidelines)
The following areas have been examined for a skin rash, head, neck, abdomen, back, upper and lower extremities. Other than the head none of these areas have been affected.
Objective - Exam 8 body areas 99214
1. Rash of the face. Have instructed to use sunscreen and return in two weeks if no improvement.
Assessment/Plan - MDM low (due to over the counter treatment) 99213
What would this level be? A 99213 or a 99214? I know that with an established office visit you can code by history and exam or by history and medical decision making.
Would this be accurate, if the MDM is moderate 99214, exam is 2-4 body areas 99213 and the HPI is at a level 99214 could I code it a 99214?
On the flip side of that if the MDM is low 99213, exam was 5-7 body areas 99214 and HPI is 99214 could I code a 99214?
Any help out there would be greatly appreciated!
Denise