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I know this question has been asked in the forum but I wanted to see if there was any difference in opinion now. Can we use Negative response for HPI elements? Such as negative for trauma or patient hasn’t take any medication. If anyone has any guidelines to support, it would be greatly appreciated.
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In order to count "head, including face" (as listed on the specialty skin exam) Can just the face be examined for your 1 point, or does it have to document BOTH the head AND face were examined in order to get the 1 bullet point.
Same question for "Chest, including breasts and axilla"–Can the chest alone be examined, and count for your 1 point, or do all 3 of those areas need to be examined in order to get the 1 bullet point?
Example- chest, arms and legs were examined. Can the chest count as 1 point, or not at all because breasts and axilla are not listed.
Any clarification is appreciated!
Coding 99495 and 99496 takes more effort than deciding whether the patient is seen 7 vs. 14 days after discharge. The CPT® guidelines for transitional care management (TCM) codes 99495 and 99496 seem straightforward, initially, but the details are trickier than is commonly recognized. Here’s what you need to know to report these services appropriately. […]
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