Wiki E&M Vs Phlebotomy

[MBOS]

One of my practices, the nurse did the plebotomy and also spent time with the patient taking the vitals etc. and billed the CPT code 99211. In her notes she only documented phlebotomy done annd nothing explaining about the vitals of time soent with the patient.
If ever audited I feel the notes donot support the CPT code 99211. Can the nurse go back and append the notes by adding an adendum to the same DOS.
If so what should be the reason as to why she didnot document the same time.

Would really appreciate if anyone can help me with this resp[onse.

 

[cheermom68]

What was the purpose/medical necessity of the 99211. If all she did was vitals and lab draw, there would be no 99211

 

[mitchellde]

not only can you not bill a 99211 for a blood draw, you cannot amend a note after the claim is submitted. There is no way a 99211 could be billed if the reason for the encounter was the blood draw. The nurse could not have a significant E&m since they can only see patients that are in the office as a follow up to a previous physician order. If the patient has a new complaint then the provider would need to visit with the patient and then yes a provider visit level with the 25 and the 36415.