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kathymoon

kathymoon

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Lansing, Michigan
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How would you code this?

1. Comprehensive History
2. Phsyical exam includes ony Vitals, i.e. weight height, pulse, pulse ox, BP
3. Plan and Assessment
Gout
Started Medrol Pak (4mg) for 6 days
Instructed to keep follow-up.

Further info - the gout is chronic This is a flare-up.

The physician codes this as a 99214.

What is your opinion
 
kathymoon said:
How would you code this?

1. Comprehensive History
2. Phsyical exam includes ony Vitals, i.e. weight height, pulse, pulse ox, BP
3. Plan and Assessment
Gout
Started Medrol Pak (4mg) for 6 days
Instructed to keep follow-up.

Further info - the gout is chronic This is a flare-up.

The physician codes this as a 99214.

What is your opinion
Click to expand...

physical exam in not apparent and MDM would be low so I would give it a 99213
 
MDM looks straightforward to me, there is moderate risk, but minimal dx and minimal complexty looks like straightforward .. I say 99212
 
99213

Hx : Comp
Ex: Problem Focused - 1 syst, Constitutional (vitals)
MDM: 2 points for dx or mgmt options - established problems, worsening
0 data points
Moderate risk - Rx drug management
Works out to Low MDM

Comp/PF/Low = 99213
 
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