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raeven.rojas@gmail.com

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Hi there, I'm currently auditing wound care charts and need assistance on this particular case.
This patient has been coming in weekly for wound care checks for a below the knee amputation. At today's visit 7/8 there was active drainage and an abscess that was incised and drained in office. It was noted that the blood draining out was clotting very quickly and the provider decided to draw labs earlier (7 unique tests). Patient was originally scheduled for a f/u visit 7/11.
Labs were reviewed 7/10 and provider had concerns of DIC. Provider called the patient and advised them to go the ER where the patient was later admitted. (NOTE: a telehealth visit was not completed nor billed out).

My question is how can the provider get credit for the MDM of reviewing the labs on 7/10 and making the decision to have the patient go to the ER if they were not seen on 7/10??
 
YenireddySrilekha said:
The provider can get credit for reviewing the labs and making the decision to send the patient to the ER based on MDM. The review of 7 lab tests and the subsequent clinical decision to recommend ER admission for potential DIC is considered moderate complexity decision-making, which supports billing for MDM, even without a face-to-face or telehealth visit. Proper documentation of the labs and the clinical rationale is key.

So, even without the patient being seen in person or via telehealth, the MDM can still be billed based on the decision-making process related to the lab review. It's also important that the provider’s documentation reflects:
  • The specific labs reviewed.
  • The clinical rationale for suspecting DIC.
  • The recommendation to go to the ER, including the urgency of the situation.
Click to expand...
Thank you, so I can count this towards the 07/08 visit? even if this happened on 07/10
 
YenireddySrilekha said:
The provider can get credit for reviewing the labs and making the decision to send the patient to the ER based on MDM. The review of 7 lab tests and the subsequent clinical decision to recommend ER admission for potential DIC is considered moderate complexity decision-making, which supports billing for MDM, even without a face-to-face or telehealth visit. Proper documentation of the labs and the clinical rationale is key.

So, even without the patient being seen in person or via telehealth, the MDM can still be billed based on the decision-making process related to the lab review. It's also important that the provider’s documentation reflects:
  • The specific labs reviewed.
  • The clinical rationale for suspecting DIC.
  • The recommendation to go to the ER, including the urgency of the situation.
Click to expand...
I believe this guidance is incorrect.

DIC would be an acute condition with threat to life/bodily function. That, and the decision to escalate to ER/hospital level of care is HIGH complexity decision making.

As for coding, if your payor accepts it, it would be coded as a separate, synchronous audio visit - 98015. You would need to document the visit fully and note >10min of discussion.
It cannot be linked back to the E&M per CPT.
N.
 
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