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Wiki Can this note be coded as anything??

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tlwhlw

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This is an example of actual note physician made; no vitals were taken, pt just here for grief counseling. Pt has BCBS insurance. Could E/M codes 99211/215 be used based on time, if time had been documented?


ADDENDUM (Tuesday November 27, 2012)

Type of Note: Addendum

Subject: grief

Additional Information: 57 Y/O SISTER DIED SUDDENLY LAST WEEKEND WITH HISTORY OF AUTOIMMUNE HEPATITIS, ON PREDNISONE X 25 YEARS. FRANK AND SHE WERE CLOSE. HE IS NOT SLEEPING WELL. GRIEF COUNSELING UNDERTAKEN. RX AMBIEN 10 MG #30 NO REFILL. F/U AS SCHEDULED AND PRN.
 
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