Wiki Determining E&M level for lab f/u

[Radcoder86]

Hello,

I'm a newbie coder and am trying to determine the level of visit for a lab f/u. The doctor wrote down a few sentences with the result numbers for the HPI, then just put the diagnoses down and detailed the patient's f/u instructions, but I have such limited information in the HPI. I have this issue all the time with lab f/u's and have the hardest time determining the level of visit, but the doctors always want to bill a 99213 when there's hardly any info documented. Can any of the lab numbers documented count towards the HPI since I'm counting them as data reviewed? If they can, all I can think to mark that would be applicable for elements would be Quality. I need help on the auditing process of these visits and what I should be telling the doctors they need to be documenting during these visits.

Thanks!

 

[emcee101]

If your doctor is counseling patients in addition to just going over their lab values, they should document the time total spent along with the "more than 1/2 of the time spent was in counseling and coordination of care" statement and then these visits could be billed based on time.

If all that is listed in the HPI is lab values than you would be hard pressed to get 4 separate HPI elements. You would not be able to have anything more than an expanded problem focused (EPF) history but this is still OK for a 99213. Assuming that a pertinent ROS is also documented this would still satisfy the minimum history requirements for a 99213 since PFSH is not needed.

With a low level medical decision making noted, which you could easily achieve with data reviewed and the number of diagnosis/treatment options a 99213 can be billed without worry. No phys. exam would be needed since an established patient visit only needs to satisfy 2 of the 3 E/M key components.

It's hard to say for sure without reading a sample of what your doctor is writing, but in theory it sounds like they could be in compliance.

 

[Radcoder86]

Thank you!!!