Wiki Chart note for Post Payment Audit of 99214!

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beach83

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"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
 
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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!!)
 
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