99212--established patient visit - Sample audited notes

by 
December 2nd, 2015

By: Betsy Nicoletti (Mon, Jun/01/2015) 

Established patient visits all require 2 out of 3 of history, exam, medical decision making

99212
History required is problem focused: 1-3 HPI elements


Exam required is problem focused: 1 body area/organ system examined from the 1995 exam, or one bullet from the multi-specialty exam or any single specialty exam from 1997


Straightforward MDM (one resolved problem, one minor problem)

See the articles on auditing and the Documentation Guidelines in Codapedia. 

There are sample, audited notes attached here.

References:

99212--established patient visit - Sample audited notes. (2015, December 2). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/99212-established-patient-visit-27970.html

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