sluke9
Guest
Having trouble with Urgent Care visits for diagnoses such as OM, URI, Viral illness, Croup/Cough, Strep Throat
HPI - usually has 4 elements
ROS - has 2-9
PFSH - either has medical history or statement that No PFSH related to present illness
Exam - templates are used that they have to fill in the results of the exam
With these templates they will have anywhere from 5-9 organ systems listed
For an acute uncomplicated illness such as one listed above would you allow a Detailed exam just because the template has so many organ systems? There are usually at least 2 bullets in 6+ areas but we use 1995 guidelines.
MDM - is generally low with symptomatic care, OTC medicine or sometimes a 1 time antibiotic.
Opinions as to whether you would give this a 99213 or 99214?
Second question...
HPI states patient is there for congestion, cough and ear pain
On exam the patient as a fever
The assessment is OM with a 1 time antibiotic, OTC for symptomatic care but nothing about the fever
Would you give the MDM a moderate due to the fever on exam?
Thanks for any opinions/help!! There are differing opinions between coders on these.
HPI - usually has 4 elements
ROS - has 2-9
PFSH - either has medical history or statement that No PFSH related to present illness
Exam - templates are used that they have to fill in the results of the exam
With these templates they will have anywhere from 5-9 organ systems listed
For an acute uncomplicated illness such as one listed above would you allow a Detailed exam just because the template has so many organ systems? There are usually at least 2 bullets in 6+ areas but we use 1995 guidelines.
MDM - is generally low with symptomatic care, OTC medicine or sometimes a 1 time antibiotic.
Opinions as to whether you would give this a 99213 or 99214?
Second question...
HPI states patient is there for congestion, cough and ear pain
On exam the patient as a fever
The assessment is OM with a 1 time antibiotic, OTC for symptomatic care but nothing about the fever
Would you give the MDM a moderate due to the fever on exam?
Thanks for any opinions/help!! There are differing opinions between coders on these.