Wiki Can any code be assigned to this?

beach83

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Hi- Auditing chart notes for a Cardiologists Group- this is a note referred to me for post audit. dos: 03/04/09. (on 02/19/08 pt. had an Adenosine Stress Test)

Dear Dr. ______,

I have seen Patient A in follow-up examination. She had a stress test performed. There was no evidence of ischemic myocardium. The ejection fraction was normal.

An echocardiogram was also essentially normal.

Overall she is doing well. She will continue with diet and risk factor modification. We will continue with her current medications.

We'll see Patient A again as needed in the future.

Signed-by Dr.-----.

(This was billed to the Ins. Co as a 99214 and paid!)
Thanks for any / all responses.
 
That is so not a 4. I would bill it as a 99212 myself unless there was additional documentation that supports time. I know my providers only dictate the letter but some have a letter and a handwritten note that you can combine.

Laura, CPC, CEMC
 
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