99211? Patient saw Med assistant but leaves without seeing doctor due to long wait..

JesseL

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Medicare patient saw Medical Assistant but left because he didn't want to wait for the doctor.

The scriber documented as below..

F/u on rash on abdomen and back
Symptom: still itchy
Duration: for awhile
Severity: intermittent
Timing: constan

Dermatitis, unspecified
Patient was check-in and waiting in the consultation room and told medical assistant that he is still itching on the body after last visit, and all he need are refill his topical cream and antihistamine pills. but patient decide to leave without seeing doctor While waiting to long in the consultation room. we had call his wife to refill his medication since patient already paid copay today., Prescription e prescribed to patient's pharmacy on file.


Would I code this as 99211 with Z76.0 for medication refill?

Thanks.
 
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There has to be a medically necessary reason for the visit. The HPI documented wouldn't be medically necessary unless the patient saw the provider. There was no medication management done, just a refill made, which would also not reach a medically necessary reason for the patient to actually come in to the office for.

There also should be some consideration given to the fact that the patient attempted to have the office visit, but was made to wait an unnecessary amount of time. Let's say the claim does get billed and paid and the patient will be left with a coinsurance to pay. If you were the patient, how would you feel getting that bill? :confused:
 
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