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Pulmonology Coding Alert

Reader Question:

Employ Appropriate E/M codes for Follow-up to New Drug Regime

Published on Sun Feb 26, 2012

Question: Our pulmonologist put one of our established patients on a new drug regime. The patient visited our office for her next appointment after a period of three weeks. During this visit, our non-physician practitioner examined the patient and recorded the vitals and checked with the patient about any adverse effects after beginning the drug prescribed. The documentation of the visit mentions that the patient was only evaluated to check about the medication being taken, and no side effects were noted. How should I report this visit?Maryland SubscriberAnswer: Since your non-physician practitioner (NPP) evaluated and assessed the patient during the visit, you can report the visit using the E/M code 99212 (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 problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination [...]
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