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documentation problem

  1. Question documentation problem
    Medical Coding Books
    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 this codable at all? maybe an unlisted E/M?

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

  3. #3
    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. Default
    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
    Greeley, Colorado
    If the doc didn't do the HPI, then 99211 would be the max.

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