# documentation problem



## mkm1517 (Jun 16, 2008)

ok, I have a doc who doesn't do much in the way of documentation (yes, they've been counseled multiple times) and they've hit a new low.  nurse documented "pt doing better on nexium and had duodenal ulcer biopsy done."  doc didn't document *ANY* hpi, ros or exam...only the dx and ordering the scope and meds...is this codable at all?  maybe an unlisted E/M?  
Thanks!


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## PatriciaCPC (Jun 17, 2008)

You know how it goes.... if they didn't document it, they didn't do it!!!


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## FTessaBartels (Jun 18, 2008)

*99211*

99211 requires only a chief complaint.  I know it's considered a "nurse visit" but there is no rule that says a physician cannot bill this CPT code. 
F Tessa Bartels, CPC-E/M


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## rharmon (Jun 19, 2008)

If there is a CC - does have brief HPI "doing well on Nexium" and dx and stated doing a procedure would do a 99212.  Have you stressed it from the point of $$ :0)   What about trying a simple template for this person who hates to document but is doing the work?


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## Lisa Bledsoe (Jun 19, 2008)

If the doc didn't do the HPI, then 99211 would be the max.


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