Wiki E/M outpatient visit

[Lmurf]

Hi
I'm hoping someone can help.
Can I bill an established outpatient visit for my gastro doc?
Here is discharge summary from Short Stay.
30 year old female pt came in to outpatient short stay for scheduled colonoscopy with rectal bleed and anemia.
hx of boderline hypertension. On toprol. Pt also has palpitations
Physical exam done
bp checked, murmur
lung: clear
abdomen: benign
rectal: negative in office
labs showed hg & hct of 10 & 31 mcv of 72
Pt given a screening urine pregancy test which was positive and then a serum pregnancy test done. She was then deemed high risk for iv sedation. Then seen by ob/gyn who recommended not to undergo procedure
consult: ob/gyn
Procedure obviously never started and pt was discharged from short stay but doc examed her, ordered test and consult.
Thanks in advance for any help!!!!
Linda

 

[dwhitney]

Your doc provided you with a nicely done Patient Encounter Form and that does qualify for an E&M level. Darlene

 

[Karolina]

I would say yes - you can bill an outpatient visit. Was this patient previously seen by you doc (or another one in the group)? If so, that would make her an established patient.

 

[Lmurf]

Thanks for your help. I would use the e/m code with a POS of 22 since it was a hospital short stay facility.
Linda

 

[ARCPC9491]

What a way to find out you're pregnant!