Wiki New to e&m help needed with visit please

staticsis2

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e&m help needed with visit please

1). A 25 year old New patient , who had a tray fall on right wrist at work today, comes to the office. She has persistent pain exacerbated with moving the wrist and hand. She describe pain as very servere. Righ wrist is swollen and sore to touch. Her past medical history is noncontributory and she has NKA. Provider performed an expanded problem focused examination. An x-ray was ordered and showed no acute fractures. Dx: right writs sprain. Patient was placed in padded splint and give prescription for Darvocet. She was asked to return in one week. The level of E/M that should be billed is:

I choose 99201 - please provide your input.

Thank you.
 
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It would help if you explained your reasoning. I'll break down how I would score it.

HPI - Extended
ROS - Pertinent
PFSH - Pertinent
Expanded Problem Focused History

Expanded Problem Focused Exam

One new problem w/o add'l workup needed, X-ray reviewed, Prescription Drug Management.
Moderate Medical Decision Making Complexity.

An EPF History and Exam with Moderate MDM easily satisfies the requirements for a 99202.
 
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