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SOAP note for E&M Service

  1. Unhappy SOAP note for E&M Service
    Medical Coding Books
    Can anyone assist me for my own piece of mind? Attached is a SOAP note that I received for a chart review. I personally don't see that it meets all requirements for a E&M, but I could be wrong. Please, any advise would be greatly appreciated.
    Attached Files Attached Files

  2. #2
    Milwaukee WI
    Default 1995 guidelines
    Per 1995 guidelines you have

    EPF exam (BP recorded and "chest clear")

    MDM - LOW (2 problem pt for established problem worsening - "BP Up" / Moderate risk for Rx management)

    This equals a 99213 established patient visit per 1995 guidelines. (But I agree that this is pretty sad documentation ... not to mention hard to read.)

    F Tessa Bartels, CPC, CEMC

  3. Default
    FTessa Bartels- I agree this is poor documentation and normally my supervisor have us take it back to the provider and have them to rewrite or add to the note. Ofcourse they are bothered and upset by it but I tell them it's this way or I code a lower level or its doesn't get billed. (I work for health dept so things are a little different then private practices....not sure if that's a good thing though)

  4. Default
    thank you for your help

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