Wiki How would you code this?-Physician discussed

[vyaden]

Pt already has established PCP with whom she is satisfied. All the patient came for was to get a referral, nothing was done. Physician discussed that appt with actual psychiatrist must be made by patient. She was given number to schedule appt and number to suicide/crisis hotline. Also advised to call 911 or go to nearest ED for thoughts of harm or suicide.

 

[Ashley0925]

Code as an E/M

The physician had to do an evaluation of the patient's medical condition and he did help manage the condition by giving the patient a referral.
If that was all that was discussed during the visit was the patients mental condition and a referral given then I would code it a 99212 using depression as the diagnosis.

 

[chilipepper218@gmail.com]

What kind of provider is it? Were vitals taken? Was there a chief complaint, HPI, ROS, Physical Exam of any kind?

 

[chilipepper218@gmail.com]

Why would you give depression as a diagnosis Ashley0925? Did I not see this information provided by vyaden? We cannot make assumptions

 

[Rfayecarter@aol.com]

Unsure of E/M level but diagnosis should be counseling and referral related.

I would suggest a New/Establish Patient Consult Visit. Seems like it was face to face encounter with some counseling. Unclear on exam details and I suggest diagnosis V68.81 or V65.50 (icd9) or Z09.4 or Z71.9(icd10).

Rita

 

[teresatark]

You need to go back and "query" the provider of the service and ask for more clarification.

 

[mitchellde]

There is nothing to go on with what is stated in this post. If you post the actual note it would be more helpful. There is no way to even conjur a DX code based on the information provided, much less a visit level. To me, right now, with the info provided, there is no visit to code.

 

[BenCrocker]

At best it's a cousiling encounter. But as Debra said it's hard to code so not billable without a query.

 

[vyaden]

History as well as vitals were taken, but no exam. Under her past history it states Bi-polar, so I am leaning towards going with that diagnosis and assigning a new office visit code.