daisygirl
Contributor
I am auditing a note for E/M service where the provider (an internist) is using a dx of
V76.51, screening malignant neoplasm colon
CC: GIA for screening colonoscopy
HPI: Abdominal pain, has burning after food, not on daily treatment. Heartburn frequently aggravated with food for the past 6 months
ROS: Denies Constipation, diarrhea, nausea, rectal pain, rectal bleeding and vomiting
EXAM:
GENERAL APPEARANCE: pleasant, NAD
HEART: regular, normal S1, S2, no murmurs
LUNGS: clear, no crackles or wheezes
ABDOMEN: soft, BS present, no guarding or ridigity, no masses felt
ASSESSMENT: V76.51
TX PLAN: Start Golytely Solution Reconstititued, 236 GM, 1ml now orally once a day
Question:
This is an internist, is it appropriate for him to use this dx for this visit, since he is not doing the actual screening?
Even though this is an established patient, he coded this visit 99202.
V76.51, screening malignant neoplasm colon
CC: GIA for screening colonoscopy
HPI: Abdominal pain, has burning after food, not on daily treatment. Heartburn frequently aggravated with food for the past 6 months
ROS: Denies Constipation, diarrhea, nausea, rectal pain, rectal bleeding and vomiting
EXAM:
GENERAL APPEARANCE: pleasant, NAD
HEART: regular, normal S1, S2, no murmurs
LUNGS: clear, no crackles or wheezes
ABDOMEN: soft, BS present, no guarding or ridigity, no masses felt
ASSESSMENT: V76.51
TX PLAN: Start Golytely Solution Reconstititued, 236 GM, 1ml now orally once a day
Question:
This is an internist, is it appropriate for him to use this dx for this visit, since he is not doing the actual screening?
Even though this is an established patient, he coded this visit 99202.