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Chart note for Post Payment Audit of 99214!

  1. Default Chart note for Post Payment Audit of 99214!
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    "pt. name", is a longstanding patient of mine. I am awaiting transfer of her records from my previous group.

    To the best of my recollections, she has a history of a fusiform abdominal aortic aneurysm measuring approximately 4.5 cm at maximum transverse diameter for which we chose not to proceed with operative intervention and previously she had an out-patient ultrasound performed that showed this to be a 4.7 by patient history.

    I am in the process of obtaining an abdominal CTA with pelvic views. I will see her back in the office to discuss these findings and be sure to keep you infirmed of further findings. I hope to be in receipt of her prior records by then as well

    Signed by physician.

    That is the extent of the note that billed/paid with a 99214 code!

    Any other ideas regarding any code that could be applied here? I am thinking no code assignment based on the note info?!!

  2. #2
    Milwaukee WI
    Default 99212
    History = PF
    CC: aneurysm
    HPI: location (abdominal aortic) & severity (4.5 cm)

    PE - none

    MDM: Problem points = 1 (established, stable)
    Data points = 1 (abdominal CTA ordered)
    Risk = moderate (? ... but you don't need this)
    MDM is Straightforward based on problem points and data points.

    Result is 99212: PF history and Straightforward MDM

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 08-06-2009 at 01:17 PM.

  3. #3
    Was the patient even there? It doesn't look like it to me from the note. It just looks like a quick letter to another provider, not an office visit note.

    I don't think I would bill this myself.

    Just my opinion,

    Laura, CPC, CEMC

  4. #4
    Milwaukee WI
    Default Yes, of course, patient must be present
    Of course the patient must be present ... Laura is correct.

    The way I read it originally, I had in my mind that the patient was seen.

    F Tessa Bartels, CPC, CEMC

  5. Default
    Thanks for response(s)....-(At first I also wondered if pt. was in the exam room!!)

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