Wiki Follow-up level

[veloso]

For follow-up of an established dx. like LYME DISEASE can we bill for 99213 but the Phy.Exam was only the measurement of the vitals since the Provider told me that there's no need to do another exam for follow-up encounters?
Thanks a lot.

 

[Jagadish]

To bill 99213, the provider should document EPF History, EPF Exam and MDM Low. If 2 out the three requirements is met you can bill 99213. If not it should be downcoded.

 

[jdibble]

He could bill a 99213 as long as the History is Expanded and MDM is low. Even if he did not do anything for an exam, he only needs 2 of the 3 areas to be at the same level.

 

[mitchellde]

I agree but it sounds like the MDM is going to be straitforward if it is followup to an already estb dx and tx plan. So it could easily be a 99212.

 

[Jagadish]

If the est problem is stable or improving it would be 99212 but if there is no change in its severity, then it would be 99213. Anyways, if you can provide the complete documentation that would be better.

 

[veloso]

This is the complete DOCUMENTATIONS and thanks a lot EVERYBODY for the input:

CC
SEIURE F/U.
HPI:
Seizure Disorder
LABS FROM LAST WEEK ARE ESSENTIALLY NORMAL WITH WBC VERY SLIGHTLY ELEVATED AT 10.9, WITH NORMAL DIFFERENTIAL. CALCIUM NORMAL, SODIUM NORMAL. NO NEW SX.MRI OF BRAIN WITH CONTRAST WAS COMPLETELY NORMAL. WAS A NEUROLOGIST WHO IS TO HAVE EEG DONE AQND D3CIDE IF SHE IS A CANDIDATE FOR LONGTERM SEIZURE MEDICATION.
Current Medication:
None
Medical History:
Allergies/Intolerance:

Gyn History:
OB History:
Surgical History:
Hospitalization:
Family History:
Social History:
ROS:

Objective:
Vitals:
HR 81, BP 125/80, Ht 64, Wt 116, BMI 19.91
Past Results:
Examination:
General Examination
UNCHANGED FROM LAST WEEK
Physical Examination:

Assessment:
Assessment:
EPILEPSY NOS W INTR EPIL - 345.91 (Primary)
Nevus, pigmented, of skin of trunk - 216.5

Plan:
Treatment:
EPILEPSY NOS W INTR EPIL
AWAITING EVALUATION BY NEURO.
Nevus, pigmented, of skin of trunk
TO SEE DERMATOLOGY FOR ROUTINE NEVUS EVALUATION
Others
WILL CONSIDER CHANTIX AND SMOKING CESSATION AAFTWE DECISION IS MADE RE: ANTIEPILEPTICS.
Procedures:
Immunizations:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Next Appointment:
CPT VISIT CODE:99213