General Surgery Coding Alert

Question: My surgeon reported an established patient office visit code 99214, but the only note in the chart is a letter back to the referring doctor detailing the patient’s condition. The surgeon insists that this is the way he has always done things, and there has never been a problem before. Is this acceptable? It doesn’t seem right to report a code without a standard progress note format.

Utah Subscriber

Answer: You might be able to bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) based on the letter, depending on what information it contains.

Is there a chief complaint, review of systems, medication reconciliation, and other similar documentation in the letter that supports 99214? If so, then it should hold up as documentation of the patient’s visit.

If, however, the letter simply states, “Thank you for referring Mr. Jones. I concur with your diagnosis of hiatal hernia and recommend surgery,” then you won’t meet the criteria for 99214 because you don’t have enough information to support the code.