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Documentations needed?

  1. Default Documentations needed?
    Exam Training Packages
    I have two queations?
    1.For all established visits does it NECESSARY that the ROS should be documented in each encounter OR it could be blank for level 99213-99214 and if not documented I just take the Elements from the Phy.Exam. and MDM and not the HISTORY for 2 OUT 3 if it meets the 2 components required (using the 1997 DG) to bill for 99213-99214?

    2.What if I have only 2 status or inactive chronic illnesses in the HPI (1997 DG) can it qualifies for 99214?

    Thank you.

  2. #2
    Location
    Central Pittsburgh
    Posts
    164
    Default
    have two queations?
    1.For all established visits does it NECESSARY that the ROS should be documented in each encounter OR it could be blank for level 99213-99214 and if not documented I just take the Elements from the Phy.Exam. and MDM and not the HISTORY for 2 OUT 3 if it meets the 2 components required (using the 1997 DG) to bill for 99213-99214?
    The guidelines indicate that for established patients, you do not NEED one element over another to meet your level. If you are billing a 99213 and you do not have ROS, you should have documentation in the other areas (exam, decision-making). Without ANY ROS and using history to meet your level, the highest you are able to bill is a 99212.

    2.What if I have only 2 status or inactive chronic illnesses in the HPI (1997 DG) can it qualifies for 99214? I would then use the HPI elements or the 1995 guidelines.

  3. Default
    Hi Ms.Guru,
    Thank you very much for your input,with regards to question number one that is very much understood and with regards to question number two can I switch to 1995 DG? if ever I'm short of elements because I'm using straightforward 1997 DG or else I'll have to educate again the Providers regarding the 1995 DG.

    Once again thank you very much.

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