tci General Surgery Coding Alert - 2013 Issue 4

Reader Question: Letter May Provide E/M Documentation

Question: My surgeon reported an established patient office visit code 99214, but the only note in the chart is a letter back to the referring doctor detailing the patient’s condition. The surgeon insists that this is the way he has always done things, and there has never been a problem before. Is this acceptable? It doesn’t seem right to report a code without a standard progress note format. Utah Subscriber Answer: You might be able to bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2...

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