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  1. #1
    Default Exam
    Medical Coding Books
    If you have the patient's vitals and the statement examination remains unchanged what level of exam would you assign to this? Thanks for your help.

  2. #2
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    Quote Originally Posted by NESmith View Post
    If you have the patient's vitals and the statement examination remains unchanged what level of exam would you assign to this? Thanks for your help.
    Wow! That's all that was documented? Hum!! You would have a problem focused exam but what was the chief complaint? Just curious.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
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    Patient states they are here for a two week follow up is the chief complaint

  4. #4
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    Quote Originally Posted by NESmith View Post
    Patient states they are here for a two week follow up is the chief complaint
    Follow up to what?
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default 99211
    99211 would be the highest I could come up with, given the very limited info available.

    Of course, this would require a chief complaint.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Location
    Central Pittsburgh
    Posts
    164
    Default
    At best, you have a 99212. You cannot refer to a previous exam. You must illustrate in your documentation the exam elements for each visit.

    But adding that chief complaint, the 99211 might cover it. However, follow up from what? A surgery? A previous issue? A required follow-up?

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