June Allen
Member
provider 99213 & 87880 & 99000, dx 465.8 (acute URI), 780.60 (fever)
CC = fever started yesterday, 102.7 highest, sore throat
HPI = fever (assoc s/sx), 102 degrees yesterday, today 100.1 by forehead this morning (timing) and gave ibuprofen (mod fx) 3 hours ago and onset of symptoms 1 day ago (duration) 4 HPI elements = Extended
ROS = no ear pain, has nasal congestion since yesterday (ent), no cough (resp), no diarrhea, no vomiting (gi), no headache (neuro) 4 ROS elements = Extended
PFSH = current meds - pertinent
Exam = neck, const, eyes, entm, cardio, skin, resp, gi, neuro, lymp. Each BA or OS reflect "no problems"
Services = strep w/optical = negative & specimen handling
Patient Indtruction: "if fever in 3 days return. Symptomatic tx for URI. Will send out back up throat culture to rule out strep"
MDM= credit only yo presenting problems "acute uncomplicated illness. *no dx procedure??? no mgmt options
?1. *Even with the assay optic service, where would or do I place that (in resk table - dx procedure ordered)even if I wanted to give credit?
?2. There is not documentation via exam or impression (pt instruction) that the patient has URI. I feel if it is not a definative diagnosis, especially since no meds either OTC or script were give, then sym & sx (fever) should be the only I9 submitted. Correct?
?2. As 2/3 required for est pt, documented hx & exam suppost 99214 but, medical necessity support using provide code 99213. How would I educate teh provider?
Thank you!
CC = fever started yesterday, 102.7 highest, sore throat
HPI = fever (assoc s/sx), 102 degrees yesterday, today 100.1 by forehead this morning (timing) and gave ibuprofen (mod fx) 3 hours ago and onset of symptoms 1 day ago (duration) 4 HPI elements = Extended
ROS = no ear pain, has nasal congestion since yesterday (ent), no cough (resp), no diarrhea, no vomiting (gi), no headache (neuro) 4 ROS elements = Extended
PFSH = current meds - pertinent
Exam = neck, const, eyes, entm, cardio, skin, resp, gi, neuro, lymp. Each BA or OS reflect "no problems"
Services = strep w/optical = negative & specimen handling
Patient Indtruction: "if fever in 3 days return. Symptomatic tx for URI. Will send out back up throat culture to rule out strep"
MDM= credit only yo presenting problems "acute uncomplicated illness. *no dx procedure??? no mgmt options
?1. *Even with the assay optic service, where would or do I place that (in resk table - dx procedure ordered)even if I wanted to give credit?
?2. There is not documentation via exam or impression (pt instruction) that the patient has URI. I feel if it is not a definative diagnosis, especially since no meds either OTC or script were give, then sym & sx (fever) should be the only I9 submitted. Correct?
?2. As 2/3 required for est pt, documented hx & exam suppost 99214 but, medical necessity support using provide code 99213. How would I educate teh provider?
Thank you!