Assessment and E&M code dilemma

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I have a provider who puts sometimes 10 or more diagnoses in her assessment and always wants to bill a 99214 or 99215. In the chief complaint the patient was there for a med refill for HTN or DMII and she will re-diagnose things from a list of chronic problems but not mention them in her HPI or do a physical exam. How should I approach this? I've been told I'm being too picky or demanding. What can I do to remedy this problem?
 

Chelle-Lynn

True Blue
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When she re-list the diagnosis in her assessment is she providing a current status or action plan for these conditions? Example: If she is listing hypertension is she noting stable or uncontrolled, etc.

If she is just relisting the diagnosis code then this would not "count" towards her E&M level. The condition needs to be actively monitored and assessed during that visit to be counted. While the provider may not have listed documentation under the history section or the exam section, if they provide enough information in the assessment section to show that they are actively reviewing that diagnosis during that days visit then it can be taken into account.

It is a tricky issue and it comes down to how the diagnosis are being documented.
 
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The provider could list 100 diagnoses, but as previously mentioned, there needs to be a remark as to the status of each one. Without a statement indicating "stable", "controlled" or "uncontrolled", you'd be stuck trying to level those. You can only bill what actual work was done, and if the provider never addresses any of the additional diagnoses, then no work was put into evaluating those, therefore they cannot be considered part of the work done.

The gray area comes into play when a diagnosis that isn't documented as directly addressed, but is a contributing factor to something that IS addressed.

The bottom line above all else is medical necessity. If the patient is there for med checks and refills, does that really meet the medical necessity of a 99215-level visit?
 
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