Wiki Need to know e/m level ??

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MsMaddy

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I JUST WANT TO KNOW WHAT E/M LEVEL WOULD YOU USE FOR THIS VISIT IN THE BOTTOM. PT HAS HMO INS. I JUST NEED AN OPINION. I DON'T FEEL THIS DICTATION IS COMPLETE.

THANK YOU ALL IN ADVANCE
MSMADDY:cool:



S: Patient is here for recheck. Has been feeling very well. Has had no new symptoms. Feels like he is doing quite well.

O: Exam, no change. Lab work is reviewed.

A: 1) HYPERTENSION.
2) STATUS POST CVA.
3) HYPERLIPIDEMIA.
4) BORDERLINE DIABETES.
P: 1) Will increase simvastatin from 40 to 80 mg. Recheck in 3 months with lab again.
 
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I would have a hard time billing for this. "recheck" of what? No CC. Also he/she states "exam- no change" - no change from when? I am no expert in auditing my any means but this does not seem like enough documentation to me.
 
I agree. The documentation here does not support an E&M code. More than likely, enough work was done to bill an E&M code, but it is not documented, therefore, not billable.
 
Follow-up for WHAT

I keep telling my physicians ... your chief complaint CAN be follow-up but you need to tell me "follow-up for WHAT"?

If you doctor had said "recheck status post CVA" You'd have a billable service. If this is a relatively recent visit, ask doctor to ammend documentation to clarify chief complaint.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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