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Sufficient for a 99212?

  1. #1
    Post Sufficient for a 99212?
    Medical Coding Books
    I have two surgeons in the same practice who perform many colonscopies and EGDs, which do not have a global period. One physician wants to bill every follow up to non-global scopes as global, the other feels they should bill a level as there is not follow up period. Here is an example of a follow up note...there is no exam, but it could meet problem focused history and straightfoward decision, a 99212?? I'm looking for guidance, input, information on how the insurance would view this documentation. What is appropriate?

    DATE OF SERVICE: August 3, 2011

    HISTORY OF THE PRESENT ILLNESS: Patient returns today 4 weeks after undergoing colonoscopy with normal findings and anoscopy with banding for anal mucosal prolapse and today she is here doing well. The patient has no complaints at this time, stating that she is very pleased with her response to treatment that was done for anal mucosal prolapse. I informed this patient that if she has any ongoing problems or new problems that develop, I would be more than happy to assist with care, otherwise she is advised to continue to follow with Dr. Primary Care for her ongoing medical needs.
    Last edited by AR2728; 08-11-2011 at 10:16 AM.

  2. #2
    Ellenville, New York
    Default Exam?
    At first read of this documenation, I don't see any exam elements. I know that only 2 of 3 are required, but I am always a little uneasy with using the three key elements with no exam. Maybe if they record the time spent discussing these things with the patient you could get a time-based code???

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