Disability Evaluation with E/M

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I have a patient who presented for follow up for cervical disc disease adn chronic pain syndrome. I have Problem focused history, Expanded Problem Focused examination and moderate decision making. In addition, the doctor completed a form for a social security/disability claim. It included Date of last examination (same date as SOAP note), DX, Symptoms, Physical Findings, Evaluation of limited activity, work related restrictions, calculation of estimated absence from work due to disability, etc. I would like to code as a 99213 with possibly a 99455 or 99080. Any thoughts?

Thanks for any input/insight.
 
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4,456
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Milwaukee WI
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not 99455

Well, the MD didn't do two exams, and the follow-up was scheduled (or so it seems from your scenario)...
So, I'd bill the 99213-25 and 99080.

F Tessa Bartels, CPC, CPC-E/M
 
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