Wiki Consult or Admit?

[Gemini18]

Good Morning -

I have a chart I am reviewing -- it is billed as a 99252.

Date of admit - 7/16/08, Date of consult - 7/16/08

Primary Care Physician - Dr. A
Requesting Physician - Dr. B
Dictating Physician/Consultant (Dr. I am reviewing) - Dr. C

Reason for Consult - Management of CAD, COPD and CVA

Dr. C does a complete H&P, an extended ROS, complete Exam.

DX:
1. History of arrhythmia, currently asymptomatic.
2. Chronic obstructive pulmonary disease/bronchial asthma
3. Cerebrovascular accident

There is no request from the requesting physician to do a consult. Am I correct to code this as an admit?

 

[Lisa Bledsoe]

I would check with the hospital first to see if they have an admit note from Dr. A or B and who they have listed as the admitting physician. You may have a subsequent hospital visit on your hands.

 

[Karolina]

It looks like a subsequent daily visit without the request. I completely agree with Lisa.