SUBJECTIVE
44 y/o established patient here for a recheck of a URI. He was seen at our clinic 3 days ago. He has been ill for a total of 6 days. I reviewed the note on 12/29/22: COVID and Influenza POCT were both negative. CXR was negative for infiltrate. He was prescribed Tessalon Perles 200 mg TID PRN for cough. He states he is not feeling better. His cough has improved with Tessalon but he still has a low grade fever up to 100.1. Appetite is decreased and taste and smell “are gone”. His wife tested positive for COVID 4 days ago. He is taking OTC ibuprofen for fever and achiness.
Past Medical History
Hypercholesterolemia
Current Medications
He takes Lipitor 10 mg daily and aspirin 81 mg daily.
Drug Allergies
NKDA
OBJECTIVE
BP 138/88
HR 108R
RR 16
Temp 99.2
SPO2 96%
HT 6’ 1”
WT 205lbs
A&OX3, NAD, speaks in complete sentences.
HEENT: Normocephalic, PERRLA, EOMI, TMs- clear, no erythema, Mouth: no erythema or exudates
Neck: No adenopathy or JVD
Lungs: CTAB, no rhonchi, rales, or wheezing
Heart: Tachy rate, no murmur
Skin: warm and dry, no edema or cyanosis
Recent results
POC COVID is positive
POC Influenza test is negative
ASSESSMENT
COVID-19 infection
PLAN
Orders Placed in the Encounter
POC COVID
POC Influenza
Facility-Administered Encounter Medications
None
Medications Prescribed During the Encounter
None
He will continue Tessalon 200 mg TID PRN for the cough. He will also continue ibuprofen for body aches and fever. Increase fluids and rest. He will quarantine for 4 more days. I sent a message to his PCP for further evaluation to include a video visit in 2-3 days to ensure he is improving. He will go to the ED for worsening of symptoms or if new symptoms arise (CP, SOB, high fever). Patient understands and agrees.
We will break this case down by referring to the 3 Elements of Medical Decision Making:
Number and Complexity of Problems Addressed
Patient presents for follow up of a URI with stable vital signs. He does test positive for COVID, but this would be a low, level 3 acute uncomplicated illness or injury.
Amount and/or Complexity of Data to be Reviewed and Analyzed
The provider ordered a POC Influenza and COVID test during this office visit. Reviewing the office visit of 12/29/22 does NOT count towards the data section since it was not an external note. The CXR does not count towards the data column for the same reason. The complexity of data would be low, level 3 (2 POCT).
Risk of Complications and/or Morbidity or Mortality of Patient Management
Although no new prescription was prescribed, the provider informed the patient to continue Tessalon for the cough so this would count towards prescription medication/management. Risk would be a moderate, level 4.
Two of the three elements of MDM must be met to choose a level of service. Problems addressed and data both met the low, level 3 criteria and risk meets the moderate, level 4 criteria so this is a 99213.
