Wiki Please help! - For a clinic visit


Kapolei, HI
Best answers
For a clinic visit, a provider has a established patient coming in complaining of soar throat. It just started the day before and is mild but getting worse. During the visit providers does a Rapid Strep just to be sure. The provider then diagnoses the patient with soar throat and prescribes no medication. The documentation supports a 99213.

Two days later the provider's labs come back to the provider and show positive for strep throat. Provider will contact patient via phone and phone order prescription medication.

Can the provider ammend their documentation to reflect the new diagnosis and also the new prescription, which will then change the visit to a 99214?

Or because it is on a different day from the date of service and the visit is already complete do they have to stay with the 99213?

Are they even allowed to make changes 2 days later just because results are in?

Please if possible list sources any regulations, etc to support ones answer. Thank you
diagnosis not confirmed at time of visit

*Coding the symptoms and signs is acceptable when diagnosis has not been confirmed.
*Code the condition to the highest degree of certainty for that encounter.

The documentation for that encounter does not change, nor do the codes. Sore throat is correct for the first visit.

Two days later, when lab results are in, and you now have a diagnosis, and a prescription is ordered, this should be documented on that day.

There is a CPT code for a telephone call 99441 but it is not appropriate in this case. (see code description in CPT). The telephone call was part of the 99213 visit that was already done.

*Section IV:Diagnostic Coding and Reporting Guidelines for Outpatient Services, E and I.