Silvia Posted Mon 06th of July, 2020 18:24:43 PM
For below video visit the doctor is billing 99213 . I don't see ROS or PFSH documented on the note. Should the correct coding be CPT code 99212?
Patient did a video visit due to the pandemic.
S - Reviewed the Vanderbilt and prior neuropsych testing. These have been scanned into the chart. Also, left message for therapist and have not heard back. Scores indicate patient has ADHD that is impairing ability to focus, concentrate and follow rules.
Appearance/Cooperation: fair groomed, appears stated age
Attitude: pleasant and cooperative
Eye Contact: good
Attention Span: attentive
Speech: regular rate and rhythm
Mood (pt's report) : ok
Suicidal Ideation: No
Homicidal Ideation: No
Thought Process: Linear and logical
Thought Content: Denies SI, HI, AH, and VH
A/P - 14 yo female with ADHD.
1. Start ritalin 5mg po qday to target ADHD. Also wrote for concerta 18mg po qday. Reviewed r/b/se/alt with parents and they agreed.
2. They will fill at Kaiser pharmacy.
SuperCoder Answered Tue 07th of July, 2020 02:18:26 AM
Hi Thanks for your question As per the medical document the key components are History PF Physical Examination EPF Based on psychiatric evaluation MDM Low E M code Since the patient is established therefore the key components required are out of Also the reviewed document i e Reviewed the Vanderbilt...