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mrolf

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How would you code this established visit: Patient brought in by mom with complaints of a rash, it started yesterday. It's been kind of itchy. It's all over his body. She doesn't know what he got ito. Han't done anything different No fever or chills. He otherwise has been acting fine. No allergies.
TEMP: 98.2 HT: 80 RESP 20 WT 42 lbs
SKIN: shows a rash over his entire body consistaent with hvies. No other abnormalities.
A. Urticaria
P. We'll put him on Prednisolone for seven days. Call us with any probelms.

Physician wants to bill 99213. I want to make sure this is correct.
Thanks.
 
Per 1995 guidelines it's a 99213:

CC: Rash
HPI: Brief (location, durations, associated signs and symptoms)
PMFSH: None
ROS: Extended (constitutional, allergies)
=Expanded Problem Focused

Exam: Skin and constitutional=Expanded Problem Focused

MDM: New w/no workup, no complexity,moderate risk(rx drugs)= moderate

99213
 
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