Pilar10
Contributor
Hi All,
I just started doing auditing at work and on the auditing worksheet tool I am getting a comprehensive history, comprehensive exam and a moderate decision making which comes out to cpt code 99204. My dilemma is that the doctor only documented a social and family history not the three history areas I need in order for it to be a comprehensive e/m level so would I downgrade the e/m to a 999203? How would this be approached?. Thank you to all for your immediate response.
Pilar CPC, CPMA
I just started doing auditing at work and on the auditing worksheet tool I am getting a comprehensive history, comprehensive exam and a moderate decision making which comes out to cpt code 99204. My dilemma is that the doctor only documented a social and family history not the three history areas I need in order for it to be a comprehensive e/m level so would I downgrade the e/m to a 999203? How would this be approached?. Thank you to all for your immediate response.
Pilar CPC, CPMA