I'm auditing for a physician that has come out as an outlier for CPT code 99214, in one particular note the physician has a comprehensive history and a comprehensive exam, but my medical decision making is a low, as the patient only had Vaginitis w/o medication RX. I understand that the MDM should be the leading factor for documentation, so besides stating to this physician that they are over documenting for a "Low" problem what would you code this visit?
99215 ( which documentation supports but not MDM)
99214 ( what the physician billed)
99213 ( what the MDM supports)
any advise would be greatly appreciated.
Thank you,
Ivonne, CPMA
99215 ( which documentation supports but not MDM)
99214 ( what the physician billed)
99213 ( what the MDM supports)
any advise would be greatly appreciated.
Thank you,
Ivonne, CPMA