Problem # 1
When you dont' have sufficient documentation to meet the standard for a 99221, use EITHER the unlisted E/M procedure code: 99499 -or- 99221-52 (reduced service modifier). This came from a seminar I attended, and was carrier specific. Some carriers wanted the 99499, others wanted the -52 modifier on the 99221. Also, be sure that you are auditing using BOTH 1995 and 1997 guidelines. Sometimes a note will meet the detailed exam level on the 1995 when it doesn't on the 1997.
Problem # 2
Everyone after the admitting physician codes subsequent hospital visits, unless there is a legitimate consult requested and documented. (That's not the case for your example.)
Subsequent hospital visits require two of the three key elements: history, exam, MDM. The Chief complaint is part of the history. Since it's missing, I would count the exam and MDM to determine level of service.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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