Wiki Is this billable, if so, how?

Create Wiki
S

SienTC1720

Networker
Messages
67
Location
Rutland, VT
Best answers
0
This is what I have, not sure if it would be a simple 99201, but what diagnosis would I use? The patient is set up for colo 10 days after this appointment.

S. Referred for a screening colonoscopy. He is due and is being seen in the office because of question of his renal function. He sees a nephrologist and the last visit was in May of this year. In reading the nephrology note his creatinine is 2. He has stable renal function and at that time there was some concern about his blood pressure with diastolic being slightly elevated. However now this has been brought under control.
P. I have advised him I think we can proceed with colonoscopy with sedation with no problems and I have set him up for this.

Can we just use V76.51, even though this isn't the screening itself?
 
No you cannot use the screening code unless you are performing the actual screening at that encounter. I can only think of a V code for pre op but this is not truely Pre op. Maybe one of the administrative V codes?
 
This is not billable as documented above with no exam. The new patient visits require 3 of 3 elements so at least one exam element would be needed even for a 99201.
 
This reads like a visit for clearance for surgery to me. I won't say whether it is billable or not as there could be more to the note than shared here. Ideally, this looks like an encounter that would be billed based on time as the physician likely spent most of the time discussing the status of the patient's renal condition and whether the patient could safely undergo the procedure. Of course, that requires documentation of the face-to-face time and time of counseling. Code V72.83 (other pre-procedural exam) would seem the appropriate first-listed diagnosis code.

The ICD-9 guidelines that apply are:
For patients receiving preoperative evaluations only, sequence first a code from category V72.8, Other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

The V code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.

The screening V code categories:

V28 Antenatal screening

V73-V82 Special screening examinations

I hope this helps at least for future reference.
Cindy
 
Thank you for all the responses! I didn't even think about 3/3 for the E&M level, that would have made it a no-brainer!

Being that what I showed you all is all I have for documentation, I'm going to assume that it isn't billable at all, even as counseling.
 
You must log in or register to reply here.
Top