Wiki Need help with very short chart note

ollielooya

True Blue
Messages
903
Location
Everett, Washington
Best answers
0
Dr. is a specialist in migraines. Established patient. DX= 346.10. Chart notes follow:

Pt presents for adjustment of stimulator settings. Pt. suffers from ongoing daily headaches. I recommended expanding the pulse width 3 days most distal contact point. Patient noted improvement in stimulation toleration and plans to have continuous stimulation

That's it! It was submitted as a 99214, but obviously, that is incorrect. Shouldn't there also be a code from V53.XX as well? I'm just stumped on this one. Isn't this basically a problem focused exam and at best only be assigned 99213? No exam. MDM has stalled me. Would this be an established problem, worsening, or "stable" at this point? For "presenting problem" I have "moderate", and Management Options ????

Can someone turn on a light for me, please? Perhaps it should be sent back asking for additional information?

Suzanne E. Byrum CPC
 
Top