An established, 66-year-old male patient with rheumatoid arthritis who was last seen in the office three weeks before returns to the office for an infliximab infusion. The patient reports mild pain in his right knee, right and left elbows. He rates the pain severity at a 3 on a 10-point scale. He denies any weight gain or loss, fever, cough or dyspnea, and has no known allergies. The patient receives methotrexate via subcutaneous injection and takes ranitidine. The provider provides a problem-focused exam. The patient receives his infusion of 400 mg infliximab, and the infusion takes two hours and 16 minutes.
The claim is billed as 99213-25, 96413, 96415, J1745x40.
Was the claim billed accurately, is there a need to query the physician on the documentation, and why?
