Wiki 99211

[Tonyj]

Can I bill a 99211 for pt coming in for lab evaluation? No other documentation. Do I use the previous note for a diagnosis?

 

[mitchellde]

You may not use information from a previous note for the diagnosis of todays encounter. You need to look at the note itself. Is this a provider eval? if so then what criteria does it meet if it does not meet 99211 standards then use the 99211, as far as dx is concerned there should be something documented to give you a clue. If this is not a provider encounter but is say a nurse encounter then you may not use a 99211 unless the lab is documented as abnormal and indicates a need to either change the treatment or redo the lab.

 

[Tonyj]

You may not use information from a previous note for the diagnosis of todays encounter. You need to look at the note itself. Is this a provider eval? if so then what criteria does it meet if it does not meet 99211 standards then use the 99211, as far as dx is concerned there should be something documented to give you a clue. If this is not a provider encounter but is say a nurse encounter then you may not use a 99211 unless the lab is documented as abnormal and indicates a need to either change the treatment or redo the lab.

It's the nurses' note for eval of levels after administration of chemotherapy.

 

[mitchellde]

I do not think this is billable unless the labs are abnormal.