Wiki physician show the patient for diabetes check

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Portland , OR
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male presents to check for DM. Pt states he has a strong family hx of DM and has been feeling fatigued, thirsty, hungry with polyuria for years. His sister told him to get checked out. Pt states that he works a lot. Pt states that he eats a lot of rice but does eat veggies. Pt denies getting any exercise.
so billed
CPT
99214-25
36415
81002
82947

DX code
R73.09

Noe Healthnet denied the code 81002 and 36415 for integral part of the primary procedure being billed . for further explanation please see CPT guidelines in relation to unbundled edit.Do i need to need additional DX or modifier?



 
Was there an abnormal elevated blood glucose reported? If not the use the symptoms documented. You did not state that the patient had an elevated glucose prior to ordering the tests so did the patient have labs performed previous to this visit? If there is no documentation of an elevated glucose then you should not use that code
 
I'm reading your question as an issue with carrier bundling 81002 and 36415 into the office visit. There are some carriers, regardless of how many diagnoses or modifiers, that will include those codes in the visit. I would advise checking with carrier to clarify.
 
Was there an abnormal elevated blood glucose reported? If not the use the symptoms documented. You did not state that the patient had an elevated glucose prior to ordering the tests so did the patient have labs performed previous to this visit? If there is no documentation of an elevated glucose then you should not use that code

History of Present Illness:
54 yo male presents to check for DM. Pt states he has a strong family hx of DM and has been feeling fatigued, thirsty, hungry with polyuria for years. His sister told him to get checked out. Pt states that he works a lot. Pt states that he eats a lot of rice but does eat veggies. Pt denies getting any exercise. Pt denies CP, SOB.

Review of Systems:
Cardiovascular:
Denies Syncope
Endocrine: Admits Appetite Changes and Polydipsia ;
General: Admits Able to Conduct Usual Activities and Fatigue ; Denies Apparent Distress
HEENT: Admits Lightheadedness ;
Male Genitourinary: Admits Urinary Urgency ;
Neurological: Admits Dizziness ; Denies Incoordination , Visual Changes and Weakness
Respiratory: Denies Shortness of Breath
Skin: Denies Rash

Vital Signs:
Weight 130 lbs Height 5' 4'', BMI 22.31 kg/m sq, Category Normal Weight, Temp 98 F, Pulse 102 b/m , Respiration 14 b/m, BP 110/78 mm/Hg SAO2 98% Taken on Aug 31, 2019 at 9:11 AM by Ms Gianotti, Alyssa

Allergies:
NKDA

Current Medications:
Patient currently takes no medication
Past Medications:
Clotrimazole 1 % External Ointment: 1 Application(s) 2 times a day , Start 04/13/2019, Qty 1 Tube(s) For 7 Day(s) Refill 1, DAW, treat with topical for fungal infection as directed - Auto Completed on 08/31/2019
Triamcinolone Acetonide 0.05 % External Ointment: 1 Application(s) 2 times daily , Start 04/13/2019, Qty 30 Milliliters For 5 Day(s), treat for skin irritation - Auto Completed on 08/31/2019

Physical Exam:
Constitutional

Appearance: No distress, Alert and oriented x 3
Head and Face
Head: Inspection: No sig rashes
Neck
Range of Motion: Supple
Respiratory
Respiratory Effort: No acessory muscle use no distress; Auscultation of Lungs: Normal breath sounds
Cardiovascular
Findings: Regular rate and rhythm, no murmurs/rubs or gallops
Skin and Subcutaneous Tissue
General Inspection: No gross abnormality noted on exposed skin surfaces
Neurologic
Gait and Station: Ambulatory
Psychiatric
Judgment and Insight: Appears appropriate; Mood and Affect: Affect appropriate


Assessment And Plan:



Lab Result:
08/31/2019 82947 - GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP
Fingerstick Blood Glucose239
Added: Gianotti, Alyssa 08/31/2019 9:16AM
08/31/2019 81002 - UA Dip
LeukNeg
NitritesNeg
Urobili0.2
Protein15
pH5.0
BloodNeg
Specific Gravity1.025
Ketone40
Bili+
Glucose++++
Added: Gianotti, Alyssa 08/31/2019 2:04PM

Procedures:
Phlebotomy FEE (CPT-36415), Units: 1.

Diagnoses:
Blood glucose abnormal - R73.09

Prescription:
metFORMIN HCl 500 MG Oral Tablet: 1 Tablet(s) 2 times daily , Start 08/31/2019, Qty 60 Tablet(s) For 30 Day(s)

UA with glycosuria and ketones ++\++++ without symptoms. Do not think pt is in DKA at this time. Discussed emergency s/s. Treat with metformin 500mg BID. Discussed GI SE. pt verbalized understanding. Pt will get glucometer and check fasting daily. Diabetes education provided including dietary changes and longer term effects of high blood sugars and dangers of low BG. f/u in 1 week here in clinic to discuss results and provider further DM education. Pt will make f/u apt with PCP as well.


This is patients chart note.
 
when your dx. Ode is the same for the visit as well as the test, the paye does have a tendency to deny the Ua as being a part of the visit. So for one I see no reason for the 25 modifier, then for some payers I find that I do need the 59 on the ua it goes back to an old bundling edit that most payers removed but some still have., also add the code for family history of DM, also since the abnormal result is another symptom I would add in the other symptoms you have documented. Now for the 36415, I see a finger stick documented which would be the 36416 and perhaps that is the reason for that denial, also some consider the collection of the blood an integral part of the lab test and not separately billable. I hope this is of some assistace
 
when your dx. Ode is the same for the visit as well as the test, the paye does have a tendency to deny the Ua as being a part of the visit. So for one I see no reason for the 25 modifier, then for some payers I find that I do need the 59 on the ua it goes back to an old bundling edit that most payers removed but some still have., also add the code for family history of DM, also since the abnormal result is another symptom I would add in the other symptoms you have documented. Now for the 36415, I see a finger stick documented which would be the 36416 and perhaps that is the reason for that denial, also some consider the collection of the blood an integral part of the lab test and not separately billable. I hope this is of some assistace

Thank you
 
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