Once the provider states that the primary reason for the visit is counseling, you can theoreticaly bill a 99215, so long as the time spent counseling matches the time typically spent for a 99215.
However, then the burden of documentation is to include the time spent counseling the pt and a detailed note of the topics/issues addressed and the medical necessity of the counseling. Both seem to be lacking in the documentation.
If your provider wishes to document monitoring of potentially toxic medications there are medical policies acknowledging instances where this is medically necessary.
Had documentation indicated that the provider reviewed and considered various lab values, presence or absence of indicators of toxicity or complications or even concerns affecting MDM regarding pt response/tolerance to such medications, the answer might be yes. However his/her documentation doesnt include any documentation that drug toxicity was a large part of his/her medical decision making or even the purpose of the visit. There are lab values listed, but no reference to them regarding the provider's use of their values to monitor or continue or change the treatment plan.
Concerns regarding toxic drug effects may well have been the reason for the office visit and would certainly be medically appropriate. But while that may have been the case, the documentation does not clearly or adequately reflect that. Dont mean to sound harsh. I'm always reminding my providers, clearly state your concerns and reasons for continueing or changing a treatment plan in writing. If its not in written, i cant see it.
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