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Wiki Vaccines and Med Refill 99212

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tbird1971

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I need a little help. My provider selected 99212 as the billing level for this visit. I do not feel it supports an E/M visit. Can someone else give me some input on their thoughts? I want to explain to her more documentation needs to be added, the CC only states immunizations. Under problems, it shows onset of problems as date 04/04, but that was the date of the appt. I told her I felt this was a 99211. Any thoughts? I have redacted this document to show what I am looking at. Thank you!!Sample note_Page_1.jpgSample note_Page_2.jpgSample note_Page_3.jpgSample note_Page_4.jpgSample note_Page_5.jpg
 
I agree that an E/M would not be reportable, since there is no CC (in my opinion).

I would bill only the vaccines and administration.

I don't think a 99211 would be appropriate.

I am interested in any other opinions.
 
To me, this is a provider documentation education opportunity.
1) CC - stating "history of" could be interpreted as patient previously had, not currently has. I'm pretty sure the provider meant those are current problems.
2) Continue meds under HTN and hyperthyroid but I don't see where it's documented which meds are for which problem(s).
3) Did the provider evaluate the HTN, hyperthyroid, and/or hyperlipidemia?? Again, what took place and what the provider intended is not 100% clear on the page.
In reality, it seems the patient has 2+ chronic stable problems, with a decision to continue those medications. That would be 99214. However, the documentation does not state the problems are chronic. The "onset date" of the date of the encounter probably has something to do with how the provider entered that in the EHR. The "continue medications" statement does not indicate which meds.
With accurate, better worded documentation, I could easily see this as 99214. With the current documentation, I would hesitate to bill any E&M.
 
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Was this truly an office visit or was it an encounter for an immunization? I'm leaning towards recommending billing the immunization only. 99211 bundles with the vaccine admin and wouldn't be separately reportable per the NCCI edits. If the provider truly performed an E/M service and didn't just carry the information from the last visit forward, then I would say that this is a great opportunity to educate the provider about the benefits of clear, concise documentation so that you can support the use of a modifier.
 
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