What documentation is required to back up a bill for a 99214 visit?
There are three sets of documentation guidelines issued by HCFA--the 1995, 1997 and 2000 versions. The 2000 version is not official, but a draft was released in June 2000, and those guidelines will be pilot-tested in the coming year.
Documenting a 99214 visit means addressing, in the progress note, 2 of 3 aspects of medical work--history, physical examination and medical
decision-making. History is subdivided into 3 sections--history of present illness (HPI), review of systems (ROS), and past, family and social history
(PFSH). Documenting a 99204 (new patient) visit means addressing, in the progress note, all 3 aspects of medical work.
This tip is excerpted from a recent issue of The Green Sheet, a newsletter on compensation and reimbursement for nurse practitioners, published monthly by the Law Office of Carolyn Buppert.
Subscriptions: $25 per year (12 issues), mailed first class. To receive The Green Sheet every month, mail your name, address and a check for $25 to Law Offices of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD 21403.
