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Wiki Examination HELP!!

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yvette31

Networker
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32
Location
Pico Rivera, CA
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I'm not sure what to do in this situation and really need some advice.
My physician seen a patient in the hospital did a comprehensive HPI and MDM but was not able to perform a cardiology exam: my phydician stated the below on his report:

"Because of religious reasons the husband refuses to allow any males to examine his wife. He did allow me to place my stethoscope on her chest and I did not hear any pericardial friction rub".

How do I code this?

Many thanks in advance.
 
It depends on if this is a subsequent hospital visit or initial/consult. Because of the comp history, I'll assume that it is an initial/consult. If it is an initial, your option is to bill based upon time or 99499 (unlisted E&M code) or use 99231-99233 (using 2 of 3 for history/mdm). If it is a consult, your option is 99251 (one exam was done) or to bill based upon time.

Good luck.

Erin
 
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