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E/M Consults

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.

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