tci E/M Coding Alert - 2013 Issue 10

You Be the Coder: 99213 or 99214?

Question: My ob-gyn documented the following: Established patient CC: Vaginal Discharge HPI: Extended 4 day history of a constant vaginal discharge associated with odor. Nothing makes it better. Past Medical History Reviewed ROS 3+ systems reviewed Exam: Full pelvic exam but no further exam performed. KOH/Wet prep confirms bacterial vaginosis. Medical Decision Making: 1) New problem diagnosed with no further workup needed 2) New RX Flagyl given to patient How should I code this? Is it a level 3 or level 4 established patient visit? Arkansas Subscriber Answer: For this problem, you have no medical need for it...

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