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exam required?

  1. #1
    Default exam required?
    Medical Coding Books
    NP documents detailed history,moderate medical decison making , but no exam
    No time noted so cannot code on time. Is at least one exam bullet required or would
    this be a 99214? Thanks for any help

  2. #2
    Default
    Quote Originally Posted by Bellaboo View Post
    NP documents detailed history,moderate medical decison making , but no exam
    No time noted so cannot code on time. Is at least one exam bullet required or would
    this be a 99214? Thanks for any help
    For established visits you only need 2 of the 3 key components in order to qualify for a level of service. Did the doc not record/take vitals.

    Check your CPT book for the info regarding which visits require 2 or 3 key components.

    Good luck
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    Default
    No vitals were documented either, thats what makes me question it can be coded at any level . Yes 2 of 3 are required but does that necessarily mean no exam at all
    as even for a problem focused exam at least 1 element is required
    Thanks appreciate any help

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default 2 out of 3
    If the documentation meets two out of three for an established patient visit, that's what you code.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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