Consultation/Initial Office Visit no PE

[Tonyj]

Can you bill a consultation/initial OV if the patient declines the physical exam; (3 of 3 required)? I have a complete HPI with a moderate MDM. Physicians states "today's meeting limited to discussion of treatment options for prostate Ca".

 

[mitchellde]

All sources say the only choice is to bill it as an established patient level.

 

[jvanek82]

If the doctor documented the content of the counseling discussion and stated the total time of the visit he could have billed it with a new patient code based on time.

 

[mitchellde]

no since a new patient encounter must have all three key components, even for a time based encounter. However if he referrs to the vital signs and patient descrition as to mood and affect etc then you have a minimal exam and if time were documented you could potentially code based on time assuming the documentation supports.

 

[Tonyj]

All sources say the only choice is to bill it as an established patient level.

How can I bill this as an established pt if it's the pt's first visit? Does consultation allow to bill same as inpatient? Unfortunately, I can't pull anything from the note for psyche nor vitals.

 

[MikeEnos]

And they didn't document the length of the encounter, and that greater than half of the time was spent counseling the patient? Sounds like it would be an encounter where the level of service would be based on the time spent. Based on what you described, this is exactly the type of encounter that I would imagine would be based on time spent counseling. You may even have the provider add an addendum to add that statement.

As Deb mentioned, you might consider billing it as an established patient since you basically 'fell through the floor' for new pt/consult codes (you didn't meet even the minimum requirements for that category.)

 

[Tonyj]

Great information. Thanks to you all for your responses.