Wiki Progress note

sarco7

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Hello everyone:

For CPT 99213 and 99214, what type of information should be on the Progress note? I know that 99213 E/M should be used for an expanded problem and 99214 should be used for a detailed examination. Thanks in advance for your answers.
 
for a quick reference / crash course on these two levels:
99213 - 1-3 elements for HPI or status of 1-2 chronic conditions,
Problem Pertinent ROS
Exam up to 7 organ systems at least 6-11 bullets,
MDM: At least 1 established problem worsening, or 2 established problems stable, or atleast one
new problem
Low risk, and limited data review

99214- 4 HPI elements, or status of 3 chronic conditions
2-10 system ROS
Pertinent Medical, Family, or Social History
Exam up to 7 organ systems at least 12 bullets
MDM: Multiple diagnosis
Moderate Risk, and/or Multiple data review

for more detailed info, its best to go to your local Medicare contractor website and look up the E&M information. Most often there are score sheets, and tips your can use to better analyze the office note. There are many factors that can go into selecting a level of service -- this is just a quick very brief over-view. It really is in your best interest to look for a score sheet with your current Medicare contractor.

another helpful tool is E&M university http://emuniversity.com

Louise CPC

HTH
Louise CPC
 
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