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Wiki Soap notes?

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veloso

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Hi All,
How to determine the LEVEL OF SERVICE using the SOAP NOTES in which the elements are so limited and are straightforward but the Providers are coding it as 99205 and 99215 for Pain Management?

Pls.HELP and thanks.
 
Same way you would determine on any other note...you have to pick out the HPI, ROS, PFSH, EXAM, and figure the MDM. If the elements are truly limited and straightforward, it may not be a level 5. Hard to know for sure without seeing a note!

They be dealing with complex pain-management issues, but it the documentation is not there, there is nothing you can do.

( I HATE SOAP notes!!):mad:
 
Soap notes: Subjective (HPI, ROS, PFSH), Objective (Exam), Assessment and Plan (MDM)

Limited and straightforward are usually not terms associated with level 5 E/Ms. Do you have documentation to support coding the visits based on time?
 
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