Wiki Question Baby Physical and Level

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EMcoder13

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Does anyone know of any documentation that would explain when you can charge a level with an infants physical?

I had a provider give a baby a two-week physical exam and she found a heart murmur during the physical. The physical form was filled out and the only thing written about the heart murmur was 'refer to cardiologist' and the diagnosis of a heart murmur.

She charged 99391 and 99213. She clearly didn't have enough documentation, but feels that a heart murmur can be a serious problem.

Any comments would be appreciated. Thanks
 
Sick visit with preventive

Search these threads for information on sick visits with preventive. The guidelines will be the same whether the patient is 10 days old, 10 years old, or 100 years old.

Clearly just stating that she found a mumur and will refer to a cardiologist does not seem to be sufficient documentation for a sick visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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