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perkins05

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cc : blood in urine
vitals done
urinalysis done
rx given


can an E/M level be gotten from this


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99211

This documentation equals a 99211 visit. YES, a physician can use this code (even though people persist in calling it a "nurse visit").

But you really need to educate this physician about how much money s/he is leaving on the table. RX given and probably a new problem would equal a moderate level of MDM. But to get to a even a level 3 established visit, the documentation would need to have EITHER: an expanded problem focused history (1-3 elements of HPI plus problem pertinent ROS), OR an EPF exam.

The difference is about $45 PER VISIT PER PATIENT SEEN! I see that you have several questions about this kind of documentation. If your doctor is seeing 2 patients per hour x 6 hours in a day (a VERY light schedule by the way) that's $540 per day of lost revenue. Your doctor needs a serious wake up call.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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