Wiki E/M visit


Jacksonville, FL
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Can someone give feed back,supporting documentation regarding the following scenario:

The physician dictated that the patient came in basically to pick up a note to return to work. He said he gave her a note for light duty for two weeks and then full duty with no restrictions. He will see her back PRN. There is no need for further orthopedic intervention.

I beleve this is not enough information to even bill a level of service( I initially was going to code 99212, but his dictation does not relfect 2 out of 3 components for establish patients, as their is no exam, no ROS, no PFSH. A copayment was charged, and my manager said we should probaly go ahead and charge the lowest level.)

I beleve there is a medical record release form code along with a v code to charge. I haven't ran across this situation in a while, so I am not sure.
Using Medicare's guidelines for the use of 99211, services must reasonable and necessary for the diagnosis or treatment of an illness or injury. Their website indicates "the evaluation portion of code 99211 is substatiated when the record includes documenatation of a clinically relevant and necessary exchange of information (historial information and/or physcial data) between the provider and the patient. The management portion of code 99211 is substantiated when the record demostrates influence by the service of patient care (medical decision-making,, provision of patient education, etc.)." Therefore, in your scenario 99211 would not be billable. Hope this helps.

Zaida, CPC
E/M Reply

Yes this helps. Thank you. Also, do you have that website or link regarding the guidelines. This way, I can show it, to the respective individuals. Thanks again!:)