erickalm
Contributor
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
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