Wiki Level 2 coding with one DX?

[pinnaclephyserv]

I have a provider that will bill a level 2 or 3 and the only DX is I10 or E11.9 primary with no other dx. I was always under the impression not to code I10 primary and definitely not alone with a high-level E/M.

Your thoughts?

Thanks in advance,
PPS

 

[lhoot]

Hi PPS,
What type of visit is this and what else was done? Labs, imaging, further testing, Rx management, etc.
Laura

 

[pinnaclephyserv]

I see he has a box checked Medication/Labs reviewed ROS, PE, and Assessment are just Psy consult. It's a Nursing Home Visit 99309 is what he wants to bill

 

[lhoot]

A single diagnosis wouldn't necessarily be the sole determining factor of the level. It doesn't look like there's enough documentation for 99309. There would need to be:
A detailed interval history;
A detailed examination;
Medical decision making of moderate complexity.

 

[Mnmark442]

What you need to look at is the overall medical decision making. Was there medication management for the HTN or DM? Can you give any further description of the impression and plan?