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nklunk86

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Paoli, IN
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I have a visit for a patient that came in for sore throat was tested for strep, covid, and flu. Strep came back positive. Provider has dropped in several other diagnosis codes because they refilled/changed some prescriptions but nothing else is documented about these conditions...not even as to why the changes are being made. One do you take this into consideration when picking an OV level? Two do you add these diagnosis codes to the claim even though nothing was documented as to what was discussed? Provider has 99214 but I was thinking 99213 and just billing for Strep and test done during visit.
 
It seems likely there were services provided that were not sufficiently documented to code. You can only count and bill for what is documented. It may be a good educational opportunity for the provider.
 
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