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mjh1027

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Hello,


One of our providers used the below statement:
Review of Systems: Overall, negative with the exception of musculoskeletal system being positive for pain to her back and joints

Is this enough documentation to support a 99214 lvl office visit? All other examination components are well documented.


Thanks in advance for your response :)
 
I would only give credit for the positive points noted. The statement does not indicate how many systems were reviewed overall nor does it indicate an ROS form was reviewed so no credit for a comprehensive ROS.

ETA: just realized I didn't actually answer the question ;) Not enough documentation to support a level 4.
 
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Not enough documentation to support IMO. ETA if you have everything else you need to support a 4 than no problem . I just re read your post and saw last sentence.
 
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I would count this as one system for the ROS (problem pertinent), so the maximum history level you could reach would be Expanded. But remember that 99214 only requires two out of three elements (of HPI, exam and MDM), so if the exam is detailed and the MDM is moderate, then it would not matter whether or not a complete ROS is documented.
 
Hi ,
On that note ! If I can ask for coding advice regarding this question! ? Can we bill a 99213 with no Physical Exam I advice the provider it was a NO but she was told that we could ? Any help would be greatly appreciated !
 
For established patient codes, you need TWO of THREE in history, exam & medical decision making.
99213 requires 2 of 3 from expanded problem focused history, expanded problem focused exam and low MDM. If there is no exam, as long as you meet the other 2 (expanded problem focused history and low MDM), then 99213 is appropriate.
 
Thank you csperoni so much for the clarification. Now how can properly provide this information to my physician without them starting to not document physical exam and want everything 99213?.
 
I have a follow up question. If you have Detailed Exam and Moderate MDM, do all of the diagnoses treated need to also be listed in the HPI for an established patient?
 
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