I have a chart note where the patient presents with four days of runny nose, nasal congestion, cough, fever<48 hrs, sore throat, nausea w/abd pain. Symptoms improving, exposed to the flu (sibling). Provider diagnoses with influenza because the sibling is positive along with myalgia. No data and bills 99214. I'm not sure if it's correct to bill 99214 for a flu dx with no tests and no symptoms present on the physical exam. Thoughts.
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- Thread starter leelewis8011@gmail.com
- Start date
lgardner
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I don't see how this could be a 99214.
if the provider diagnosis the pt with influenza (which sounds iffy), that is an "acute uncomplicated illness or injury".
if the provider didn't make the diagnosis of influenza, only the symptoms would be counted, so "2 or more self-limited or minor problems"
so, either way the number and complexity of problems assessed, is LOW.
as you stated, no tests. was there an Rx?
with no Rx, this would be a 99212 (Low problems, Minimal data, Minimal risk.
with an Rx (with full documentation), this would be a 99213 (Low problems, Minimal data, Moderate risk, meets or exceeds 2 out of 3 elements).
hope this helps.
if the provider diagnosis the pt with influenza (which sounds iffy), that is an "acute uncomplicated illness or injury".
if the provider didn't make the diagnosis of influenza, only the symptoms would be counted, so "2 or more self-limited or minor problems"
so, either way the number and complexity of problems assessed, is LOW.
as you stated, no tests. was there an Rx?
with no Rx, this would be a 99212 (Low problems, Minimal data, Minimal risk.
with an Rx (with full documentation), this would be a 99213 (Low problems, Minimal data, Moderate risk, meets or exceeds 2 out of 3 elements).
hope this helps.