Wiki Can low level E/M be billed?

[lblandin]

Here is the situation. Established patients frequently call in with symptoms of UTI. The phone agent asks the pt to stop by clinic and leave a urine sample and adds the patient to the MA schedule. We historically do not charge for MA visits, just document they occurred. With the urines, they are often positive and so we need to involve a provider to review the chart and they usually end up prescribing antibiotic, but don’t usually consult with the patient, since their schedules are full and the pt was not on their schedule. The providers have asked if they can include the time spent reviewing the chart and entering the prescription; is there an E/M or anything that can be captured for billing in this situation?

 

[boxford]

Depending on documentation you could probably bill a 99211 with the UA (81002 or 81003). Note would need to indicate HPI, vitals would need documented as well as a note about the collaboration with the physician and what prescription was given. Follow-up appointment would also need documented, even if it's only "PRN".