I have a provider who is being audited for billing 99214 constantly
I'm having trouble understanding if he gets credit in his HPI for ROS/PFSH stating "unchanged".. he seems to do this for every encounter especially when following up. Can anyone help please?
Example of one of the documentations:
HPI
Pt with McCune-Albright syn and migraine without aura 2 x a week much improved with neurontin 600 mg po bid
ROS
The ros, pmh, fh, sh, immunizations and allergies are unchanged from the visit of 12/5/2018
Physical Exam
Constitutional: She appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: EOM are normal. Pupils are equal, round, and reactive to light.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal.
Abdominal: Soft.
Musculoskeletal: Normal range of motion.
Neurological: She is alert.
Skin: Skin is warm.
2 large cafe au lait spots
Psychiatric: She has a normal mood and affect.
BP 120/80 mmHg | Pulse 89 | Temp(Src) 98.1 °F (36.7 °C) (Oral) | Ht 5' 3.39" (1.61 m) | Wt 206 lb (93.441 kg) | BMI 36.05 kg/m2 | LMP 07/25/2017
Mcune Albright syn
Migraine without aura
rtc in 1 months
neurontin 300 mg caps 2 am and 2 at lunch and 2 at night
I'm having trouble understanding if he gets credit in his HPI for ROS/PFSH stating "unchanged".. he seems to do this for every encounter especially when following up. Can anyone help please?
Example of one of the documentations:
Chief Complaint | ||
Patient presents with | ||
• | Migraine | |
| | follow up |
HPI
Pt with McCune-Albright syn and migraine without aura 2 x a week much improved with neurontin 600 mg po bid
ROS
The ros, pmh, fh, sh, immunizations and allergies are unchanged from the visit of 12/5/2018
Objective: |
Physical Exam
Constitutional: She appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: EOM are normal. Pupils are equal, round, and reactive to light.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal.
Abdominal: Soft.
Musculoskeletal: Normal range of motion.
Neurological: She is alert.
Skin: Skin is warm.
2 large cafe au lait spots
Psychiatric: She has a normal mood and affect.
BP 120/80 mmHg | Pulse 89 | Temp(Src) 98.1 °F (36.7 °C) (Oral) | Ht 5' 3.39" (1.61 m) | Wt 206 lb (93.441 kg) | BMI 36.05 kg/m2 | LMP 07/25/2017
Assessment: |
Mcune Albright syn
Migraine without aura
Plan: |
rtc in 1 months
neurontin 300 mg caps 2 am and 2 at lunch and 2 at night