I have a note that is comprehensive History, comprehensive exam, and MDM falls into moderate. So, that leads to a 99215 for this office visit. But the provider actually selected 99213. I'm new to coding, just finished my course and trying to be very thorough and as follow the check list to pick the right e/m each time. I'm wondering if he selected a lower e/m due to medical necessity, but he is doing a referral to cardiology, patient has sore/painful mouth with a history of BCC in that location so trying OTC and if no better, possible referral.. does the referral to cardiology make the risk moderate? Other than that, no mention of rx meds, but I'm thinking between the referral and a chronic illness with exacerbation (mouth sore/hx of BCC) that qualifies for moderate.
his history has 4 HPI elements, CC, all the histories, complete ROS. Exam covers 14 areas, in detail but not all overly in depth. Those together qualify for the 2/3 needed for a 215, right?
Or should it be a 214? I think it definitely can qualify for more than 213. I just second-guess myself and don't want to do it incorrectly and get in a bad habit.
his history has 4 HPI elements, CC, all the histories, complete ROS. Exam covers 14 areas, in detail but not all overly in depth. Those together qualify for the 2/3 needed for a 215, right?
Or should it be a 214? I think it definitely can qualify for more than 213. I just second-guess myself and don't want to do it incorrectly and get in a bad habit.
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