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Reply with quote  #1 

I am wondering if you could help me with the presenting problems minimal and low.

New PT:
CC Cyst Left Forearm
HPI has small nodule L forearm.  Had prior lipoma same arm.  Worries her.
PFSH - comprehensive
Pt intake form reviewed and acknowledged; documented positive findings, all others negative.
Vitals Taken, L past forearm lipoma
Return if symptoms
1), can small be considered a quality?  If yes making 2 HPI points for a brief
ROS complete
PFSH Comprehensive,
So for the History portion, since the HPI is brief, would it be PF or EPF?  I think PF.
2) Two exam points – vitals and forearm (EPF)
3a) New prob examiner, 3 points
3b) zero data reviewed
3c) Risk – Self limited verses Acute uncomplicated – would a cyst qualify as Acute uncomplicated illness?
If no, I get SF Medical Decision Making, if yes it would be low Medical Decision Making
Now I know that for new pts you must have 3/3, but for the sake of knowing which is best to mark and discuss with the providers for auditing purpose, can you help me with more examples of what would be self-limited or minor, verses an acute uncomplicated illness or injury. 
Where would a cyst, or lipoma fall? 
Am I on track that they would be self limited?
I know with the rest, it would be a 99201, but I still need to know if it had been an EP visit.
Thanks for helping the newbie. 

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Posts: 773
Reply with quote  #2 

I'm thinking self-limited or minor problem here.  As far the history, we would give credit for an EPF history.  The exam would only be PF.  MDM would be straightforward, so right 99201 level of care.

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