# uti help



## perkins05 (Jan 6, 2011)

cc : blood in urine
vitals done 
urinalysis done 
rx given


can an  E/M level be gotten from this


help


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## cheermom68 (Jan 6, 2011)

*Uti*

did the doctor see the patient face to face?


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## perkins05 (Jan 7, 2011)

Yes but he does not document much.


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## FTessaBartels (Jan 7, 2011)

*99211*

This documentation equals a 99211 visit.  YES, a physician can use this code (even though people persist in calling it a "nurse visit"). 

But you really need to educate this physician about how much money s/he is leaving on the table.  RX given and probably a new problem would equal a moderate level of MDM.  But to get to a even a level 3 established visit, the documentation would need to have EITHER: an expanded problem focused history (1-3 elements of HPI plus problem pertinent ROS), OR an EPF exam.  

The difference is about $45 PER VISIT PER PATIENT SEEN!  I see that you have several questions about this kind of documentation.  If your doctor is seeing 2 patients per hour x 6 hours in a day (a VERY light schedule by the way) that's $540 per day of lost revenue.  Your doctor needs a serious wake up call.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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