Admit codes (99221-99223)
99221 requires a detailed or comprehensive history, detailed or comprehensive exam and medical decision making that is straight forward or low complexity.
99222 and 99223 require comprehensive hx, exam, and moderate (2) high (3) medical decision making.
My issue, what if the doctor is only documents an EPF exam but meets the detailed history and high complexity MDM. These codes are 3 of 3, so I am thinking we can't bill anything.
Obviously this is an educational issue but the charges I am working on are approaching a year old and the physician is no longer with us so I am just trying to clean up a mess.
The other problem I am having is when a patient is being followed by multiple providers, sometimes up to 6 different providers in an inpatient stay. What do you do when the primary care provider comes in and has no cheif complaint, minimal documentation and the only diagnosis they list are truly being mananged by the other providers (specialists) who are also seeing this patient each day.
Example of a progress note (these are of course handwritten)
"Feels well, l CTA, AB soft, IV site ok, pt INR NIT
A&P SP CABG, Hx of grafted vein, Hx of DVT, HTN"
This patient is being followed by both the cardiothoracic surgeon and her cardiologist among others and just had the CABG procedure 3 days prior to this. This note was by the IM doctor.
Advice and opinions are greatly appreciated.
Thanks
Laura, CPC
99221 requires a detailed or comprehensive history, detailed or comprehensive exam and medical decision making that is straight forward or low complexity.
99222 and 99223 require comprehensive hx, exam, and moderate (2) high (3) medical decision making.
My issue, what if the doctor is only documents an EPF exam but meets the detailed history and high complexity MDM. These codes are 3 of 3, so I am thinking we can't bill anything.
Obviously this is an educational issue but the charges I am working on are approaching a year old and the physician is no longer with us so I am just trying to clean up a mess.
The other problem I am having is when a patient is being followed by multiple providers, sometimes up to 6 different providers in an inpatient stay. What do you do when the primary care provider comes in and has no cheif complaint, minimal documentation and the only diagnosis they list are truly being mananged by the other providers (specialists) who are also seeing this patient each day.
Example of a progress note (these are of course handwritten)
"Feels well, l CTA, AB soft, IV site ok, pt INR NIT
A&P SP CABG, Hx of grafted vein, Hx of DVT, HTN"
This patient is being followed by both the cardiothoracic surgeon and her cardiologist among others and just had the CABG procedure 3 days prior to this. This note was by the IM doctor.
Advice and opinions are greatly appreciated.
Thanks
Laura, CPC