Please keep in mind that these are Medicare/Medicaid patients if that makes a difference.

__________________________________________________ __________________________________________________ ____________________________________________

For established outpatient office visits, the documentation only requires TWO out of THREE of the required level of History, Exam and Medical Decision Making.

This being the case, if you have a note that contains a Comprehensive History, Comprehensive Exam, and Low Complexity MDM would that not be completely billable as a 99215? There is a divide between people wanting to bill based on the documentation and the information provided, and people wanting to bill based solely on the Medical Decision Making who would bill the above as a 99213.

If anyone has any information that could help swing this disagreement one way or the other, it would be greatly appreciated.

Thank you.