documentation problem

mkm1517

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ok, I have a doc who doesn't do much in the way of documentation (yes, they've been counseled multiple times) and they've hit a new low. nurse documented "pt doing better on nexium and had duodenal ulcer biopsy done." doc didn't document ANY hpi, ros or exam...only the dx and ordering the scope and meds...is this codable at all? maybe an unlisted E/M? :confused:
Thanks!
 
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99211

99211 requires only a chief complaint. I know it's considered a "nurse visit" but there is no rule that says a physician cannot bill this CPT code.
F Tessa Bartels, CPC-E/M
 

rharmon

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If there is a CC - does have brief HPI "doing well on Nexium" and dx and stated doing a procedure would do a 99212. Have you stressed it from the point of $$ :0) What about trying a simple template for this person who hates to document but is doing the work?
 
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