Prescription Drug Management in Medical record

Q. During an evaluation and management visit, what constitutes “prescription drug management?” A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.Note: Simply…

Pre-payment of evaluation and management code 99215

First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high comprehensive error rate testing (CERT) error rate for evaluation and management service pertaining Current Procedural Terminology (CPT®) code 99215 (Office/outpatient visit established). CERT reviews indicated the errors were based on insufficient documentation, medically unnecessary services and services incorrectly coded. Documentation…

Office visit CPT code 99201, 99202, 99203, 99204, 99205 – Requirements

CPT codes and requirements99201 – 10 minutes (average) • Problem focused history. Documentation needed:• Chief complaint• Brief history of present illness• Problem focused examination. Documentation needed:• Limited examination of the affected body area or organ system• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):• Minimal number…

Hospital visit CPT code 99221, 99222, 99223 Requirements

Evaluation & management tips: Initial hospital care, new or established patientKey points to remember The key components (elements of service) of evaluation & management (E/M) services are:1. History,2. Examination, and3. Medical decision-making.When billing initial hospital care, all 3 key components must be fully documented in order to bill. When counseling and/or coordination of care dominates…

Established CPT code 99211, 99212, 99213, 99214, 99215 Requirements

Evaluation & management tips: Office or other outpatient services, established patientKey points to remember The key components (elements of service) of evaluation & management (E/M) services are:1. History2. Examination3. Medical decision-making. When billing office or other outpatient services for established patients, 2 of the 3 key components must be fully documented in order to bill…

E & M Visit Q & A – Do physician required to document the date in Medical record – Observation care?

Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time? A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states: For a physician to bill the initial observation…