Looking for some advice on billing an E&M for PT/INR checks/monitoring. We have some providers who are billing either a 99212 or 99211 when monitoring these monthly with the documentation as shown below in each note rather than billing the 93793. By looking at the note it seems like they are managing the antibody studies abnormal (Cardiolipin disorder) but it is also in every visit stated this way monthly and billed with the E&M code. The PT/INR is not the same for every visit. Any advice or references that can be provided is greatly appreciated.
Assessment / Plan
1. Warfarin monitoring status -
PT/INR: 2.1 today. Goal: 2.0-3.0. Continue current dose: 1 tablet Tues and Sun, then 1/2 tablet all other days. Good rate and BP control today. Z51.81:
Encounter for therapeutic drug level monitoring
* PT/INR -
Specimen source: Blood capillary
2. Antibody studies abnormal -
Stable presentation today on current treatment. Tolerating medications well with no bleeding. No changes needed today. We will continue to monitor closely. R76.9: Abnormal immunological finding in serum, unspecified
- INR: 2.1
RTC in one month for follow up.
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