We recommend a couple different things for this problem. It is tough these days to know what is appropriate for billing when coding office visits. What we suggest is that you first make sure that your documentation is sufficient for whatever level of code you are submitting; and second, if you are still unsure request a report from CMS stating the averages in your area and specialty.
Many of the new EMR systems will automatically code the visit for you based on the information you scribe while seeing the visit. You do not have to accept the level of code, but it will recommend what your documentation supports. If you are not sure where to find the report and your local CMS rep is giving you problems, contact us and we will help you obtain this report.
Hope this helps.