Coding Help-

KristiMass

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Patient comes into practice and had slammed his finger. The patient explains to the physician he was already treated by a physician and provided a splint and referred to another specialists. The patient comes in with pain and would like to have his fingernail removed. Vital signs were taken by nurse. The physician did not remove fingernail and only discussed the situation with the patient.
The physician did not review any symptoms but spoke to the patient for about 10 min.

How would I bill for this? None of the office visits criteria assist.
 
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New or existing patient?

Well, without seeing the actual documentation I cannot give you a definitive answer. But consider the following:

If it's a new patient you MAY be able to use time spent in counseling/coordination of care to achieve a 99201. (Please review all the posts about this before taking this option; there are strict documentation guidelines.)

If it's an existing patient:
99201 only needs a chief complaint
99202 needs a chief complaint, 1 element of HPI, and straightforward MDM

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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