e/m leveling

  1. M

    Wiki Prescription/leveling help

    Hi everyone, If a provider is seeing a patient for a self-limited problem (level 2) with minimal MDM and orders a refill-prescription drug management (level 4) would the E/M be a 99212 or a 99213? I am having difficulty deciding the best way to level the visit. Thank you
  2. N

    Wiki HPI in E/M Leveling

    When leveling a GI office visit where the reason for the visit is to plan a screening colonoscopy with no presenting problems, what information are we allowed to use under the HPI section of an E/M Leveling sheet? My team lead and I are trying to determine if we can use "location" since we know...
  3. D

    Wiki HPI Copy and Paste

    I have a Hospitalist that copies the ER provider's HPI and pastes it into their note with "Per ER MD:" as the title. Is this allowed? My gut tells me no, but I have searched all over to find a guideline that specifically states that the provider must document in their own words, but have been...
  4. J

    Wiki INPATIENT --- Over My Head

    Hello! My name is Jordan and I am recently employed in a Colorectal Surgeon practice that also houses a GI doctor for IBD and they all do Inpatient rounds as well as procedures and surgeries. This office has lacked a coder, biller, A/R person for at least a year and is in just a mess. I have a...
  5. baroquecoder

    Wiki Medical Necessity beyond purview.

    I am being told that validating E/M's to some extent is beyond my purview. Specifically medical necessity. I am being told that it is beyond my scope to recognize/question/or validate E/Ms with regard to their medical necessity. I am being told that we are to 'assume' that if the MD states in...
  6. S

    Wiki ADD/ADHD Consults

    I had a meeting with my providers and a question came up about when they have add/adhd evaluations. They wanted to know if they are allowed to charge a 99213 even though they did not exam the patient. I told them let me get some advice and I will let you know. I thought about it last night and I...
  7. A

    Wiki Do you see a comprehensive exam here?

    Do you count 8 organ systems for a comprehensive exam? Patient is in a coma. VITAL SIGNS: BP 100/60, HR 90, Intubated on vent, sedated. Weight 171 kg. HEENT- face is cushingoid CHEST: bilateral rhonchi ABD: soft EXT: legs show edema NEURO: corneal and gag reflex absent. No movement or...
  8. A

    Wiki Does referring to a specialist or a "Consult" counts for "additional work up" ?

    Does referring to a specialist or a "Consult" counts for "additional work up" ? Does referring to a specialist or a "Consult" counts for "additional work up" when leveling e/m visits? and also what are some examples of "drug therapy requiring intensive monitoring from physician in the "risk"...