- To:
- Subject: coding question number 61
- From: Michael Sachs <>
- Date: Sun, 17 Aug 1997 10:42:41 -0700
>>Return-Path: <>
>I think I'm just going to code this visit as a regular well visit because
>my thought processes were not very complex--
>I'll have to admit that this gathering of information was more for my
>edification-
... Kim Burlingham, MD
>
>
Remember, the CPT code is based on history, physical, and/or decision making (if not using the time component). I bet if you looked at the CPT criteria, just gathering the information would have required a complex history. And if you do a head-to-toe exam on almost any child (especially this one) you've satisfited the requirements for a complex physical exam. Now that you've met two of the three requirements, the medical decision making can be simple and the visit can still be coded as 99215 as long as the office note clearly documents the H & P. Now you just have to decide which four of the multiple diagnoses available will be used on the HCFA form.
Michael Sachs, M.D.