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is this enough?

  1. Default is this enough?
    Medical Coding Books
    Pt comes in two weeks after a cystoscopy with urethral catheterization to review the findings and discuss a plan. No physical exam is performed. No HPI documented. Can I code for this?

  2. #2
    Unless time is documented, no you can't. You have to have 2 of 3 or time.

    Laura, CPC

  3. #3
    Milwaukee WI
    Default 99211
    99211 doesn't require much more than a chief complaint. Although most everyone refers to this code as "nurse visit" CPT does NOT restrict its use by physicians.

    If you have no counseling/coordination time noted, then you could use 99211.
    (I'm assuming the procedures performed don't have a 90-day global period.)

    F Tessa Bartels, CPC, CPC-E/M

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