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Soap notes?

  1. Default Soap notes?
    Exam Training Packages
    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
    Location
    Kansas City, MO
    Posts
    431
    Default
    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,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. #3
    Post
    Same here. I HATE SOAP NOTES TOO.
    Girish Dadhich, CPC

  4. #4
    Default
    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. Default
    Thanks a lot for all the INPUTS now I know I'm doing it right...

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