We all know that it takes two out of three or three out of three to qualify for a code. My question is about the four other contributing factors to be considered when leveling an e&m visit. Specifically "nature of presenting problem".

With the advent of electronic records the visit documentation is easily inflated to two out of three. providers copy and paste-(which should not be allowed) history and exam and then MDM is blank. I have seen 99214 billed for suture removal, insect bite, sprained finger, and simple colds.

does it seem appropriate to bill a 99214 for those types of visits? I do see this. My thought is a 99211 sb for those Suture removals and maybe a level 2 for the others above. 4 and 5 should be limited. If we are using level 4 for the above where does that leave lacerations, amputations, burns, crush injuries, and heart issues, cancer care, major illnesses? Shouldn't that be the real basis of the level and not a bunch of copied history, radiology,lab and exam notes?



Just a thought.