Question Level 2 or 3?

[ksrodgers]

I'm having an impossible time leveling this visit.

A patient comes in to request discussion for vasectomy at a PCP visit. The PCP puts in a referral for vasectomy.
That is all the note states. The provider does not do an evaluation or give a summary of his discussion (if he had one) with the patient. Only states "Referral to urology sent."

Thoughts?

 

[sls314]

I'm having an impossible time leveling this visit.

A patient comes in to request discussion for vasectomy at a PCP visit. The PCP puts in a referral for vasectomy.
That is all the note states. The provider does not do an evaluation or give a summary of his discussion (if he had one) with the patient. Only states "Referral to urology sent."

Thoughts?

Is the note complete enough to code an E/M visit at all?

 

[amyjph]

We would have to see the whole (redacted) note to know. Why did they even come in at all, they have an HMO and have to get a referral?

 

[beulastella]

We would have to see the whole (redacted) note to know. Why did they even come in at all, they have an HMO and have to get a referral?

please check the patient is established patient to the PCP and any related condition identified earlier, if yes will code 99212

 

[amyjph]

please check the patient is established patient to the PCP and any related condition identified earlier, if yes will code 99212

Respectfully disagree. We can't know what the E/M is, if there even is one, without seeing documentation. Was this patient even seen or did they come in and just pick up a form or an electronic referral was put in? Could this be possibly a level 2? Probably, however, without seeing the documentation fully, it can't be coded. This seems to be a family planning type visit. There is a possibility of coding it by time if time was documented properly. Especially if it was more a discussion face to face. It "might" be a 99212 if the patient was established. I would imagine there was more to the note if the patient was seen face to face by the provider. Especially if the practice has an EMR/EHR, like chief complaint/reason for visit, history, ROS, anything else? Even if the provider would have said, We discussed the procedure, he is low risk, he takes no meds, or takes X, Y, Z meds, listing any conditions he may have, I referred him to urology. This is probably a documentation improvement scenario to talk with the doc about.