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Thread: documentation problem

  1. #1

    Question documentation problem

    AAPC: Back to School
    ok, I have a doc who doesn't do much in the way of documentation (yes, they've been counseled multiple times) and they've hit a new low. nurse documented "pt doing better on nexium and had duodenal ulcer biopsy done." doc didn't document ANY hpi, ros or exam...only the dx and ordering the scope and meds...is this codable at all? maybe an unlisted E/M?

  2. #2


    You know how it goes.... if they didn't document it, they didn't do it!!!

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default 99211

    99211 requires only a chief complaint. I know it's considered a "nurse visit" but there is no rule that says a physician cannot bill this CPT code.
    F Tessa Bartels, CPC-E/M

  4. #4


    If there is a CC - does have brief HPI "doing well on Nexium" and dx and stated doing a procedure would do a 99212. Have you stressed it from the point of $$ :0) What about trying a simple template for this person who hates to document but is doing the work?
    Last edited by rharmon; 06-19-2008 at 06:49 AM. Reason: spelling :0)

  5. #5
    Join Date
    Apr 2007
    Greeley, Colorado


    If the doc didn't do the HPI, then 99211 would be the max.

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