E/M Level 99214

syoulio

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Can someone answer this? Can an MD charge level 99214 when the patient is NOT seen for a visit , and only a refill of 1 medication was called into the pharmacy? I'm thinking they cannot! Thank you!
 
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Mayzoo

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Here is my opinion, but since I am still new to coding, please do not take this as fact until a more seasoned coder comes along.......

Is this a pediatric patient, psychiatric patient, or other circumstance where a spouse, parent or guardian came in and provided history, ros, etc....instead of the patient? If yes, then s/he may be able to bill a 99214 if s/he meets the requirements during that visit.

If this does not meet the above criteria, then generally no, a physician must see the patient and perform an exam to code a 99214.

Here is a thread and an article for you to review:

https://www.aapc.com/memberarea/forums/53269-exam-missing.html

Q. Is it necessary to document all three components (History, Exam, and Medical Decision Making) for an established patient visit to bill an E/M 99211 - 99215 visit or must you bill 99499 if only two are documented. Keeping in mind, only two are required for established patients.A . Our response to this question during recent a recent teleconference and multiple seminars was all three elements were required, but only two were used in choosing a procedure code. In response to questions from the physician community, we took this question to CMS. The 1995 and 1997 DG provide general principles of medical record documentation which states: "The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services." The information then goes on to state in part:
"The documentation of each patient encounter should include:
i. Reason for the encounter and relevant history, physician examination findings, and prior diagnostic test results
ii. Assessment, clinical impressions, or diagnosis
iii. Medical plan of care
iv. Date and legible identity of the observer. "


https://www.physicianspractice.com/coding-patient-thats-not-present
 
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thomas7331

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Can someone answer this? Can an MD charge level 99214 when the patient is NOT seen for a visit , and only a refill of 1 medication was called into the pharmacy? I'm thinking they cannot! Thank you!
All E&M office visit codes in the range 99201-99215 require a face-to-face service - these cannot be coded if the patient was not seen as you have described.
 
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Hello,

I agree with thomas7331; the patient wasn't seen for a face-to-face visit and provider simply called in a prescription over the phone so this not a billable e/m service.
 

twtcpc

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Hello,

In pediatrics we do have some payers that will allow an E/M for the parents/legal guardian to come to the office and discuss their child's care with the provider without the child present - we limit this to established patients only though. The E/M is based on the CPT guidelines of counseling time and if we know ahead of time, we will contact the insurance company and have had the parents themselves contact their insurance company and have been given approval to do this. Now, we do this with the clear understanding that they can only do this under special extenuating circumstances and should not by any means be a routine practice. The provider then documents who was present, the content of the discussion/counseling provided, why the child was not in attendance, and the total time. We have even actually had a payer agree to reimburse us for a phone call with the parent (patient was established and the call was requested by the parent) because the parent had extenuating circumstances and could not come in to see the physician even without the child. We do not encourage these situations, but sometimes things do happen and sometimes the payers are agreeable to doing their part to assist.

Now in your case of billing it for a Rx being called in...No, I would not advise and strongly discourage the provider from doing this. I would not even recommend the 99211 that was mentioned above either.
 
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