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efuhrmann

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Pt comes in two weeks after a cystoscopy with urethral catheterization to review the findings and discuss a plan. No physical exam is performed. No HPI documented. Can I code for this?
 
Unless time is documented, no you can't. You have to have 2 of 3 or time.

Laura, CPC
 
99211

99211 doesn't require much more than a chief complaint. Although most everyone refers to this code as "nurse visit" CPT does NOT restrict its use by physicians.

If you have no counseling/coordination time noted, then you could use 99211.
(I'm assuming the procedures performed don't have a 90-day global period.)

F Tessa Bartels, CPC, CPC-E/M
 
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