Tierni Posted Wed 19th of August, 2015 12:44:00 PM
Our provider saw a patient who had a staff infection. The provide then wanted the patient to return to the office the following day due to the patient having a visual lesson on his head that she had drained, and wanted to monitor.
When the patient returned, the provider billed a 99213 for the follow up. She also had billed this same level for his first visit. Would level 3 E/M be justified to bill even though the visit was "only" for a follow up??
It is my understanding the provider would not complete a level 3 for back to back visits when the second visit is only for a follow up.
I want to make sure we are not over billing. Would someone please provide us with guidance? Appreciate the help.
SuperCoder Answered Thu 20th of August, 2015 07:58:23 AM
No, this is not over billing. You are right. Level 99213 is based on the selection of the elements of History, Physical Exam and Medical Decision Making (MDM). There is no role of being follow-up visit when you are coding it on the different date of service. Hope it helps!