Wiki Can this note be coded as anything??

[tlwhlw]

This is an example of actual note physician made; no vitals were taken, pt just here for grief counseling. Pt has BCBS insurance. Could E/M codes 99211/215 be used based on time, if time had been documented?


ADDENDUM (Tuesday November 27, 2012)

Type of Note: Addendum

Subject: grief

Additional Information: 57 Y/O SISTER DIED SUDDENLY LAST WEEKEND WITH HISTORY OF AUTOIMMUNE HEPATITIS, ON PREDNISONE X 25 YEARS. FRANK AND SHE WERE CLOSE. HE IS NOT SLEEPING WELL. GRIEF COUNSELING UNDERTAKEN. RX AMBIEN 10 MG #30 NO REFILL. F/U AS SCHEDULED AND PRN.

 

[jettagirlfl]

Since he is prescribing somegthing, I would give him a 99212- you could use him not sleeping as a element like constitutional.

 

[mitchellde]

It states this is an addendum note. Was there an office visit already documented for this date and billed