tci Part B Insider - 2013 Issue 7

Reader Question: E/M Format Shouldn't Matter

Question: My physician reported established patient office visit code 99213, but the only note in the chart is a letter back to the referring doctor detailing the patient’s condition. He insists that this is the way he has always done things, and there has never been a problem before. Is this wrong? It doesn’t seem right to report a code without a standard progress note format. Answer: The answer depends on what information you can find in that letter. Is there a chief complaint, review of systems, medication reconciliation, and other similar documentation  in the letter...

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