I still maintain that if the physician documents suffiently for a 99215 then that is the level we apply. It is not up to a coder to second guess what a physician should review or not review for a given visit. Follow the 95/97 guidelines and arrive at a visit level from the documentation, no more that what is there and no less. If you post a sample of one of his visits perhaps we could evaluate and tell you what our assessment is.
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