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Office visit 99201

  1. Question Office visit 99201
    Medical Coding Books
    I'm not sure how to code this situation, any input would be helpful. We had a patient come in to the office as a walk in due to an accident at home. The patient was seen by the RN who had the physician come in and briefly examine the patient and made some recommendations. The RN coded the visit as nurse visit but the patient was never seen at the clinic before. After reviewing the dictation that was done by the nurse the level of service was 99201. Can I code it that way even though the physician did a brief exam and made some recommendations and the nurse took care of the rest including the dictation?

    Thank you,
    Lisa Nieft

  2. #2
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    Columbia, MO
    Posts
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    An RN cannot provide an initial eval of a new or established patient. A nurse visit may be billed as a physician level 99211. It must be an established patient with a plan of care written by the physician in the chart that the RN is following. A new patient must be evaluated and examined by the physician, so the only documentation that can count is what the physician wrote, and it cannot reference the nurse eval and be considered as the physician documentation except for the ROS.

    Debra A. Mitchell, MSPH, CPC-H

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