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Bellaboo

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NP documents detailed history,moderate medical decison making , but no exam
No time noted so cannot code on time. Is at least one exam bullet required or would
this be a 99214? Thanks for any help
 
Bellaboo said:
NP documents detailed history,moderate medical decison making , but no exam
No time noted so cannot code on time. Is at least one exam bullet required or would
this be a 99214? Thanks for any help
Click to expand...

For established visits you only need 2 of the 3 key components in order to qualify for a level of service. Did the doc not record/take vitals.

Check your CPT book for the info regarding which visits require 2 or 3 key components.

Good luck
 
No vitals were documented either, thats what makes me question it can be coded at any level . Yes 2 of 3 are required but does that necessarily mean no exam at all
as even for a problem focused exam at least 1 element is required
Thanks appreciate any help
 
2 out of 3

If the documentation meets two out of three for an established patient visit, that's what you code.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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