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Wiki E/M level help

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dda1970

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I have an established patient office visit. My physician is billing a 99214 with only the following documentation:

Chief Complaint: persistent right knee pain.

Plan: treatment options were discussed. Would recommend arthroscopy and lateral release. She will let me know if she wises to proceed.

Now I can't get to 99214 but is this enough documentation to get ANY level?? Maybe I'm overthinking it since there is SO MUCH MISSING!

Any guidance is greatly appreciated!!
 
dda1970 said:
I have an established patient office visit. My physician is billing a 99214 with only the following documentation:

Chief Complaint: persistent right knee pain.

Plan: treatment options were discussed. Would recommend arthroscopy and lateral release. She will let me know if she wises to proceed.

Now I can't get to 99214 but is this enough documentation to get ANY level?? Maybe I'm overthinking it since there is SO MUCH MISSING!

Any guidance is greatly appreciated!!
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Really? That is absolutely it?? Not even vitals, or brief exam of the right knee? Sounds like it's time for a documentation education session. IMO, this is not a billable visit...no HPI outside of the CC, no exam...
 
dda1970 said:
I have an established patient office visit. My physician is billing a 99214 with only the following documentation:

Chief Complaint: persistent right knee pain.

Plan: treatment options were discussed. Would recommend arthroscopy and lateral release. She will let me know if she wises to proceed.

Now I can't get to 99214 but is this enough documentation to get ANY level?? Maybe I'm overthinking it since there is SO MUCH MISSING!

Any guidance is greatly appreciated!!
Click to expand...

I'm with Meagan, nothing billable as it is now. I am wondering though if the physician was thinking time-based since he/she mentions a discussion of treatment options and possible surgery, but the documentation is not there for it. Just stating that you had a discussion does not make it billable under time-based, they must mention time, a little greater detail in what was discussed, and that greater than 50% of the visit time was spent in discussion.
 
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