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OV just to view MRI results

  1. #1
    Location
    Monroe, NC
    Posts
    47
    Default OV just to view MRI results
    Medical Coding Books
    What about the doctor that indicates the OV Is just to review results of MRI? The provider just wants to say History is same as last time. Do no exam and claim a 99214 since he discussed results, refilled meds and said do some PT. It seems that there really should always be a HPI. Something doesn't seem right, thoughts on E and M just to review results?

  2. #2
    Location
    Columbia, MO
    Posts
    12,914
    Default
    He does not have to have a history review for an established patient, however there does need to be exam and decision making, or if he is going with counseling as the overriding factor the you need a time spent with the patient and a counseling note that must dominate (greater than 50% ) the encounter.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    To elaborate on what Debra answered, while new patients need history, exam, and MDM, established patients only need any two of the three. But since your provider only captured one of the three, there is no OV unless he met the conditions for time-based billing. These conditions require that at least 50% of the visit be spent in counseling and that the amount of time spent be documented in the note.

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