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Thread: Soap notes?

  1. #1

    Default Soap notes?

    AAPC: Back to School
    Hi All,
    How to determine the LEVEL OF SERVICE using the SOAP NOTES in which the elements are so limited and are straightforward but the Providers are coding it as 99205 and 99215 for Pain Management?

    Pls.HELP and thanks.

  2. #2
    Join Date
    Apr 2007
    Kansas City, MO


    Same way you would determine on any other note...you have to pick out the HPI, ROS, PFSH, EXAM, and figure the MDM. If the elements are truly limited and straightforward, it may not be a level 5. Hard to know for sure without seeing a note!

    They be dealing with complex pain-management issues, but it the documentation is not there, there is nothing you can do.

    ( I HATE SOAP notes!!)
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. #3
    Join Date
    Apr 2007
    New Delhi, India


    Same here. I HATE SOAP NOTES TOO.
    Girish Dadhich, CPC

  4. #4


    Soap notes: Subjective (HPI, ROS, PFSH), Objective (Exam), Assessment and Plan (MDM)

    Limited and straightforward are usually not terms associated with level 5 E/Ms. Do you have documentation to support coding the visits based on time?

  5. #5


    Thanks a lot for all the INPUTS now I know I'm doing it right...

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