Pt left before being seen

buppkl

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A 17 yr old patient and mom came into the office for a scheduled visit with the physician for a 3mth med check. Pt. takes Zoloft for anxiety. The CMA roomed the patient, took vitals, brief history(all things well, no complaints with meds) and before the physician came into the room, the patient left. The physician reviewed the vitals, spoke to the mom about the patient's status with the meds, instructions given and he documented all in the chart. The refill prescriptions were given to mom. Can this be billed as a 99211 or not at all? We have several different opinions going around on this scenario.
 

rthomas@impcna.com

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Our office bills 99211 if the MA,LPN have obtained at least 3 vitals and documented the Chief complaint then we have the provider document that the patient left prior to the physical exam. You could also look at CPT code 96155 (Health & Behavior Assessment w/family, pt not present) since visit was related to anxiety. We have used this when parents are concerned about child having ADD/ADHD and the patient isn't present at the visit.
 
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