Annie Posted Fri 04th of September, 2015 13:38:34 PM
A pt. has Blue Cross Blue Shield and the documentation has an HPI only a past history, no ROS, a physical exam, and plan is to proceed with surgery. What should the leveling be?
SuperCoder Answered Mon 07th of September, 2015 01:52:34 AM
If it is office consultation visit, then you need all 3 key component to report any level of Office consultation. The above query indicate that E/M visit documentation does not include any HPI. So you cannot report any level of CPT 99241-99245.