Wiki Blood Pressure check Coding

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fredcpc

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We have a nurse that Blood Pressure check on an established pt. The patient had HTN. But the nurse did not do vitals, no advice documented. No exam or history documented. Can this still be 99211? I don't think so. But how would you code this encounter? Help.;)
 
You say she did not do vitals but did she do a bp? did she document in the chart? If so the yes it can be a 99211 as long as a physician was within the office suite at the time of the visit.
 
Blood Pressure check

Here it is...we are not sure if the doctor was in the office. The documentation is very scant, that is the problem here. What it looks like is that this is an established patient that stopped by the office to have his blood pressure checked and was found to have HTN. What do think?:confused:
 
HMMMMMMMMMM.... NO. The nurse cannot diagnose HTN only the provider can do that and for the nurse to be able to charge a 99211 she has to be following up on an treatment plan already established by the physician.. no matter who the payer is.
 
Blood Pressure check

Thanks Debra. I appreciate your skill and time that you take to answer me questions. You are really helping all of us coders out in the world.
 
Blood Pressure check

You changed your picture. Elevated BP was not in the note, and still a nurse can not diagnose a patient. It was scant documentation. I did not attached a code, saying it was "insufficient documentation" and "nurses can't diagnose."

:D:cool:
 
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