Wiki Level of Service??

[Amzie]

I have a question if my ortho physician documents in his clinical notes that the patient is diabetic and hypertensive, he is not treating this at all, can this help increase his chances of coding for a 99214? Or would the physician have to also document how the co morbidities like diabetes is affecting his treatment options for the patient? I am not super great with E/M but I don't think that just stating the patient has diabetes is going to give him a higher level of service to code.

Thank you in advance

 

[dojadawn]

Level of service / Dx codes

The dx codes need to have that documentation bc the documentation supports the level of service.....one of my providers spends ample enough time and energy to support 99215 or higher BUT if she isn't treating it then it why are u coding for it??......I'm racking my brain on finding guidelines to appropriate dm documentation but I've been told if we aren't treating it then u don't need to code for it

 

[jimbo1231]

Agree

You might look at the CMS medical necessity description. I see multiple diagnoses all the time that have pretty much nothing to do with the encounter. If the physician clearly documents that they are extending the exam or doing a diagnostic because of diabetes or hypertension then clearly documenting and coding those diagnoses and extending the E&M to a higher level are appropriate. But if they are basically part of the patients medical history and nothing else in the record indicates that they are a factor in treatment then they are basically informational. Pushing documentation to 99214 based on clicking the EMR to Detailed/Detailed without medical necessity for it has been an OIG issue. That might give them pause.

Jim