You’re probably undercoding. Here are two sample office notes:

CC: Cough

HPI: 75-year-old male with productive cough for five days, worse at night. Patient also has fever and chest pain. Patient using cough syrup without improvement.

PH: Non-smoker.

ROS: Denies shortness of breath or heart palpitations.

EXAM: Vitals: temp 101.5, BP 140/80
ENT: negative
Neck: negative
Chest: rhonchi bibasilar, pain on deep inspiration
CV: negative
Abd: negative

A/P: Acute bronchitis. Rx: Azithromycin, expectorant. Follow up as needed.

* * * * * * * * * *

CC: Chest pain

HPI: 58-year-old female with intermittent, sharp chest pain over two weeks. Episodes last 10 minutes at a time. Pain occurs at rest.

PH: Non-smoker, no family history of cardiovascular problems.

ROS: No shortness of breath. No reflux.

EXAM: Vitals: BP 120/80, P 65
Lungs: clear to auscultation
CV: normal

A/P: Chest pain. ECG and stress test ordered. Follow up scheduled.

They are both 99214′s. Code without fear.

View 30 Comments >

Most Popular