When a pcp does an addiction intake in the office, such as to admit pt to a treatment facility, ie detox, sober house...but is not doing an actual full physical exam (just family hx, personal hx, substance abuse hx, bp,rr, etc) would they still use a new or existing patient code?
They are attempting to bill as new or existing level 5, but I am not sure the documentation will really support this.
The same Pcp will be seeing pt weekly while they are in the sober house, but records show that the initial is mainly a extensive paperwork intake and counseling not really a physical exam. ( I have verified this with the OM who states the physical exam usually takes place at the 2nd visit, once the patient is going through withdrawl symptoms) However they do not document the time taken for visit or counseling within the paperwork.
They are seen weekly after the inital for withdrawl symptoms and urine sampling.
However they do not document the time taken for visit or counseling within the paperwork.
I have never had to code such and just want to be sure I am doing it correctly.
Jill Martin, CPC
They are attempting to bill as new or existing level 5, but I am not sure the documentation will really support this.
The same Pcp will be seeing pt weekly while they are in the sober house, but records show that the initial is mainly a extensive paperwork intake and counseling not really a physical exam. ( I have verified this with the OM who states the physical exam usually takes place at the 2nd visit, once the patient is going through withdrawl symptoms) However they do not document the time taken for visit or counseling within the paperwork.
They are seen weekly after the inital for withdrawl symptoms and urine sampling.
However they do not document the time taken for visit or counseling within the paperwork.
I have never had to code such and just want to be sure I am doing it correctly.
Jill Martin, CPC