Ok, so alot of my providers will have established visits and put them in as 99213, 99214 but they will not preform an ROS. the ROS will read "none". I have been down coding these visit to 99212 due to them not having included a required component of the history documentation and 99212 is the only level for which its not required. I have an audit book that states that with out a ROS the note will only qualify for a 99212 as well, but then I started thinking for established its only 2/3 so if the exam and mdm support maybe I should let it go as a 99214...but deep down this still doesnt make sense because how could a high level decision be made with out a decent history?
Established, ROS: NONE...99212?
Any help or reference would be greatly appreciated!
Established, ROS: NONE...99212?
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