Wiki 99214 or 99215

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christabee

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I have been assigned to code a doctor's office visits and he uses templates with his dictations. He does edit the templates for each case. Using the leveling guidelines given to me at this facility plus the 1995 guidelines, both the hx and exam on many of his visits are technically "complete." For the established patient, would this automatically level the visit to 99215 regardless of the level of MDM? Some of these visits in question have been for a sore throat or diarrhea - hardly complex or life threatening. I would appreciate any constructive feedback on this.
 
Hi

You cannot justify a 99215 every visit due to a template. Go by the Chief Complaint and look at all the history, examination, and MDM elements based on what pertains that chief complaint, and any additional issues the patient may have. Then, determine code level. Templates are akin to electronic medical records in that the templates get "cloned" and carried over from claim to claim, but have to be pertanent to the diagnoses for the visit.
 
P.S.

Established visits require two of three components, but be careful since a 99215 based on only history and examination wouldn't necessarily be complete. Since the outcome or prognosis is essentially the final determination of the visit, the MDM is more important for a higher level of visit.
 
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