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kbarron

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Pt admitted for pelvic pain, complicated PMH. Request by PCP for gyn input re management of pelvic pain and irreg vag bleeding. I read the note and it states pt declines any Physical Exam. Further, note states" I spent 60 minutes with pt and mother discussing her concerns. The pt was able to contribute intermittently although she was extremely somnolent." I want to give it a 99253. Am being told that exam was not done. I believe that I can code it this was. Would love any and all input. Thanks
 
Counselling and Coordination of Care

You can code based on time spent if:
1) total face-to-face time is recorded (face-to-face includes unit/floor time for an inpatient)
2) amount of time spent in counseling/coordination of care (must be MORE than 50% of total)
3) Nature of the counseling/coordination of care

Your doctor has stated that s/he spent "60 minutes with patient and her mother discussing her concerns." This amount of total time would qualify for 99253 IF the physician also indicated that more than 50% of the total time spent was in counseling. This amount of counseling time (which it seems that all the 60 minutes is) would qualify for at least 99253 and maybe a higher level ... if we knew how much the TOTAL face-to-face time was.

The problem is that your physician didn't fully document. But you're on the right track. Can s/he do an addendum to clarify?

F Tessa Bartels, CPC, CEMC
 
According to the note most of the PMH was taken from Mom. Pt is 25 w/multiple medical problems. Did not want an internal exam, refused IV contrast. This after a LIH 12/23/08 at another hospital. Mom wants pt to be d/c'd asap. The note does not say the total amt of counsel. However the note is quite detailed as to what the problem is.
 
Dictate addendum

I'd ask the physician to dictate an addendum to qualify for billing based on counseling/coordination of care.

Without this, you're stuck coding on the three key elements - and with NO exam you get nothing on a consult.

F Tessa Bartels, CPC, CEMC
 
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