Wiki 99214 and 99204

[michelestr]

Is okay to bill a 99214 or a 99204 if the patient has one new problem and doctor writes a script? The reason I ask is that we had a PA at one of our clinics that was doing this and we checked with our coding dept and they said that was fine, but after looking at the notes and the problem that the patient came in for it didn't seem right. The PA was seeing patient's in an urgent care setting.

 

[ajeter]

you would need to review the documentation guidelines. If the only thing documented is a RX theat would not qualify as a level 4 visit

 

[lmartien]

Agreed - does the documentation support the level coded? Are there the necessary components of the history, exam and medical decision making. It would appear not for a simple Rx with the visit.

Linda Martien, CPC, CPC-H, CPMA