Wiki Level for Viral URI

[cnramsey]

I code for a family health clinic and we obviously see a lot of viral URI being picked by the providers. How are you coding this type of visit when no Rx is given. I feel the URI is 1 self-limited or minor problem... Providers are picking 99213 with no data and we will see this statement a lot. ( Hydration, rest, Tylenol/ibuprofen, vitamin C, lozenges, humidification.)

I would work this up as a 99212 for Dx addressed, Data None 99212 and OTC drugs Tylenol/ibuprofen 99213.

That gives me a 99212.

Thanks for all comments!

 

[thranowski]

I use this tool to assist with choosing E&M codes: https://medicare.fcso.com/SharedTools/faces/EMWorksheet_en.jspx?lob=&state=

According to that, I have to agree with you. If no testing is done and no prescriptions are given and there is no independent historians (the parent of a child), then I don't know what other choice there is. Perhaps they should start documenting by time. If they spend 20 minutes + then at least they can reach a level 3.