Initial hosp visit but no exam?

alincoln

Networker
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75
Location
Midlothian, VA
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I have a physician who was asked to perform an initial hospital visit on an elderly patient. When he got to the patient's room the family refused to let him wake the patient. He reviewed records, talked to the requesting physician and talked to the family.

We can't submit the initial hospital visit codes because there is no exam....
Any suggestions?
I was thinking:
99221-99223 if he documented how much time he spent and then billing based on time
99231-99233 since not all 3 key components are needed?

Thanks for any ideas you guys have!
 

Evelyn Kim

Guru
Local Chapter Officer
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San Antonio, TX
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based on the information given I do not see any codeable service. If the physician documented the basic information for the HPI and some sort of MDM you might be able to bill a low level hospital visit, but I would try to find out if he went back to see the patient when she was awake. It would be difficult to meet the criteria for a billable service if he did not actually exam the patient.
 

alincoln

Networker
Messages
75
Location
Midlothian, VA
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Thanks Evelyn!

No he didn't go back and see the patient. He was asked to come see the patient during the night on call. Another physician from our group saw the patient the next day.

I'm deciding between 99231-99233 or 99499 now.

Thanks for your suggestions!
 
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