NESmith
Expert
If you have the patient's vitals and the statement examination remains unchanged what level of exam would you assign to this? Thanks for your help.
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Exam
- Thread starter NESmith
- Start date
Wow! That's all that was documented? Hum!! You would have a problem focused exam but what was the chief complaint? Just curious.
NESmith
Expert
Patient states they are here for a two week follow up is the chief complaint
Follow up to what?
FTessaBartels
Guest
99211
99211 would be the highest I could come up with, given the very limited info available.
Of course, this would require a chief complaint.
Hope that helps.
F Tessa Bartels, CPC, CEMC
99211 would be the highest I could come up with, given the very limited info available.
Of course, this would require a chief complaint.
Hope that helps.
F Tessa Bartels, CPC, CEMC
SuzanBerman
Guru
At best, you have a 99212. You cannot refer to a previous exam. You must illustrate in your documentation the exam elements for each visit.
But adding that chief complaint, the 99211 might cover it. However, follow up from what? A surgery? A previous issue? A required follow-up?
But adding that chief complaint, the 99211 might cover it. However, follow up from what? A surgery? A previous issue? A required follow-up?