July 28th, 2016
There are sample audited notes in resource section.
99213 is an established patient visit which requires 2 of 3 of the following components:
An expanded, problem focused history, which is 1-3 HPI elements and 1 system in ROS reviewed
An expanded, problem focused exam, which is 6 bullets from 1997 exam or limited exam of 2-7 body areas/organ systems. Some payers and auditors use 2-4 body areas/organ systems as an expanded problem focused exams, but this is not in the original guidelines.
Low MDM, which could be one worsening problem, two stable problems or a new, acute uncomplicated illness. These are only examples, there are many ways to reach low MDM.
See the other articles in Codapedia on auditing and the Documentation Guidelines
|Resources:||Sample, audited 99213 notes (pdf)|