Wiki Help Please!

[cm@rlin]

How would you code/bill for a patient that was seen the previous day for office visit by Pulmonologsit but came back the next day to go over CT results from a different specialty (Cardiology)?

The assessment/plan from the office note from the day before states that "We will ask him to pick up his CT chest, to take a look at his parenchyma.

Wouldn't this be "bundled" into the E/M from the previous day's visit, and be considered post-work?

Any help on this would be great!!

 

[Chelle-Lynn]

When the patient returned the second day was the documentation from the second day visits only able to support another E&M service? Such as history - exam - MDM? The documentation would be the deciding factor on how the claim would be coded.

 

[cm@rlin]

No. There is only an assessment/plan, which states that the patient stopped by today for us to review a CT done at the cardiologist's office. The provider states that the patient needs a repeat study done and to return to the office for review.

 

[Chelle-Lynn]

Without additional documentation then it does not appear that the service is billable on its own.

 

[cm@rlin]

Without additional documentation then it does not appear that the service is billable on its own.

Thanks. That is what I was thinking, but just wanted to make sure.