Wiki Minimal documentation

[AlisonFaught]

I sent a note back to one of our providers for incomplete documentation. He told me it was complete but it only has 1) chief complaint 2) PFSH 3)Assessment and Treatment. There is nothing at all in the HPI and no exam documented.

The following is all that is documented:
chief complaint: fever, cough
PFSH: current medications, medical history, family history
Vitals (temp, heart rate, weight, height, oxygen saturation)
Assessment: pharyngitis
Treatment: Start Augmentin tablet 875-125 MG 1 tablet orally every 12 hours for 10 days; fluids; motrin

He wants me to charge a 99213 for this visit. I would never even consider this to be a 99213 with the current documentation. Surely he would have to document a history of present illness AND an exam to charge a 99213? I am going to send a message back to him, but I need some help in deciding how to address this issue with him. So, I have some questions:

Can I even charge a 99212 for this if he won't document anymore? Or is this note completely un-billable as it is?

 

[thomas7331]

This note is sufficient to bill 99212 - you have a problem focused HPI (signs/symptoms) and exam (vital signs), and low to moderate MDM. You could almost argue that this is 99213 if you consider either the fever or cough as a ROS, but I would consider that stretching it a bit. Not sure why you are thinking this is insufficient documentation? It's not the volume of documentation that matters, it's the content.

 

[AlisonFaught]

This note is sufficient to bill 99212 - you have a problem focused HPI (signs/symptoms) and exam (vital signs), and low to moderate MDM. You could almost argue that this is 99213 if you consider either the fever or cough as a ROS, but I would consider that stretching it a bit. Not sure why you are thinking this is insufficient documentation? It's not the volume of documentation that matters, it's the content.

Thank you for your response. It's just unusual for our providers to document this way, so I wanted the opinions of more experienced coders. Thank you

 

[thomas7331]

Thank you for your response. It's just unusual for our providers to document this way, so I wanted the opinions of more experienced coders. Thank you

Yes, in my opinion it's poor quality documentation and doesn't capture much in the way of clinically pertinent information. But it does meet minimum requirements for billing a low-level E&M code.