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Posted By Amanda on 10-04-2006, 16:54:00 in Ophthalmology
I am currently reviewing on of our doctors charts and I think that he is tending to down code.

1 Example is a patient comes their yearly exam. He has taken a detailed history, detailed exam is done but descision making was discussed dx's and Continue observation. How should that be coded. Can't bill 92014 because no treatment options were done. It seems like 99213 isn't enough but not sure about 99214?

2 Example is a patient coming in for a 4 mo IOP ck. Expanded history, expanded exam (not sure if all is med nec), and orderded VF, photos, & Pachy. Would you code 99213 for this?

Thanks for anyones opinion!

Amanda
Comments (4)
Posted By Amanda on 10-05-2006, 18:22:00
Yes I wasn't aware of that. I have not been giving them the due credit if that is true!

Amanda
Posted By james on 10-05-2006, 17:15:00
I don't believe it matters if the patient got new glasses it is the actual test that matters. The 92014 pays a few dollars more than the 99213 with decreased documentation requirements. So that is the route I would go. Otherwise, it seems the documentation does exist to code the 99213.

Anyone else?

Jim Kendrick, COA
Project Manager, EMR
Posted By Amanda on 10-05-2006, 14:05:00
So if you refract them but not give them the RX it counts? What if not what level would you chose?

I was thinking 99213 would work but wasn't confident!

Amanda
Posted By james on 10-04-2006, 19:52:00
Amanda,

As far as #1 goes, was the patient refracted? If so, that is a treatment and so can code the 92014. If not then probably not.


#2 I would code the 99213 after reviewing your info with my chart audit form, and, of course, not knowing any of the exam and diagnosis particulars.

Jim Kendrick, COA
Project Manager, EMR
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