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E&M Documentation Rheumatology

  1. #1
    Question E&M Documentation Rheumatology
    Medical Coding Books
    I am billing for a rheumatologist who sees patients with osteoporosis. Patient will have a bone density study done, is an established patient and comes in for followup to discuss bone density results. Dr reviews bone density report, adjusts/renews patients RX's but does not do an actual exam. He wants to bill a 99213 and I explained he has to do an actual exam. He feels there is nothing to examine. Everything I read for 99212-99215 requires exam? He feels his time is worth something. Is this where time becomes the factor on the E&M used? Please advise and thank you!

  2. #2
    Default
    Quote Originally Posted by aadair View Post
    I am billing for a rheumatologist who sees patients with osteoporosis. Patient will have a bone density study done, is an established patient and comes in for followup to discuss bone density results. Dr reviews bone density report, adjusts/renews patients RX's but does not do an actual exam. He wants to bill a 99213 and I explained he has to do an actual exam. He feels there is nothing to examine. Everything I read for 99212-99215 requires exam? He feels his time is worth something. Is this where time becomes the factor on the E&M used? Please advise and thank you!
    If your physician doesn't choose to do an exam ... he may use the history and medical decision component. For established patients (99211-99215) only 2 out of 3 of the components are required. So if he feels no exam, then fine - but he has to document the history and medical decision making appropriately.
    He can also use time as long as he documents the total face-to-face time. the time spent has to be 50% or more counseling/coordinating care.
    Hope this helps!

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