Wiki Well Child Visits.

[daniel]

If the documentation for a well child visit is all there. But also a quick notation at the bottom of the progress note. Like this.

Assement says: Well visit, Otitis Media

Plan: Anticipatory Guidance
Prescription Amoxicillin for 7 to 10 days.


Would and could you squeeze an an E/M 99212 for the otitis media.

Meaning your visit would look like this.

99392. V20.2
99212.25.382.9


Let me know your input.

thank you
resepectfully
Daniel
CPC

 

[FTessaBartels]

Not if you don't meet the bullet points

Daniel,
If this is the ONLY piece of documentation on which you are trying to base your E/M code ... No.

For a 99212 you need two of the following three:
Problem focused Hx
Problem focused Exam
Straightforward MDM

If this snippet of documentation you provided is all you are basing your coding on, then all you have is
Chief Complaint
One component of MDM (risk - for Rx)

So, no you can't squeeze a 99212 out of this. You can, get a 99211, which only requires a chief complaint. And YES, MDs can bill this code. Just because it is a low-level E/M that "may not require" the services of a physician (quote taken direct from CPT), doesn't mean that it is strictly used for "nurse visits."

If you do have additional documentation that you can pull your bullet points from, then of course you can bill the separate E/M code as appropriate.
And don't forget the -25 modifier on your E/M code.

F Tessa Bartels, CPC, CPC-E/M

 

[dmaec]

very nicely put FTessaBartels! I agree 100%, so I figured why write my own message.... it would just repeat what you wrote!
{that's my opinion on the posted matter}

 

[daniel]

Hey great response, I agree.

Can any of you give me a quick example of a level 2 (established) Patient. For a Otitis Media, or even a cough.

Write out a scenario, so I can see what documentation you've come across for these types of DX's.

Just trying to soak up all the different aspects of people points of views on this.

Respectfull
Daniel
CPC.

Would you squeeze out a level 99212 (established). If your note read.

Chief complaint: Tuggin and pulling at ear

HPI: Inflammation of the ear, pass 2 days.

Plantitis media, Augmentin 7 to 10days.