• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Chart note for Post Payment Audit of 99214!

Create Wiki
B

beach83

Guest
Messages
7
Best answers
0
"pt. name", is a longstanding patient of mine. I am awaiting transfer of her records from my previous group.

To the best of my recollections, she has a history of a fusiform abdominal aortic aneurysm measuring approximately 4.5 cm at maximum transverse diameter for which we chose not to proceed with operative intervention and previously she had an out-patient ultrasound performed that showed this to be a 4.7 by patient history.

I am in the process of obtaining an abdominal CTA with pelvic views. I will see her back in the office to discuss these findings and be sure to keep you infirmed of further findings. I hope to be in receipt of her prior records by then as well

Signed by physician.


That is the extent of the note that billed/paid with a 99214 code!

Any other ideas regarding any code that could be applied here? I am thinking no code assignment based on the note info?!!
Thanks..
 
99212

History = PF
CC: aneurysm
HPI: location (abdominal aortic) & severity (4.5 cm)

PE - none

MDM: Problem points = 1 (established, stable)
Data points = 1 (abdominal CTA ordered)
Risk = moderate (? ... but you don't need this)
MDM is Straightforward based on problem points and data points.

Result is 99212: PF history and Straightforward MDM

F Tessa Bartels, CPC, CEMC
 
Last edited:
Was the patient even there? It doesn't look like it to me from the note. It just looks like a quick letter to another provider, not an office visit note.

I don't think I would bill this myself.

Just my opinion,

Laura, CPC, CEMC
 
Yes, of course, patient must be present

Of course the patient must be present ... Laura is correct.

The way I read it originally, I had in my mind that the patient was seen.

F Tessa Bartels, CPC, CEMC
 
Thanks for response(s)....-(At first I also wondered if pt. was in the exam room!!)
 
You must log in or register to reply here.
Top