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Wiki Is this billable?

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Lancaster, NY
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He presents with a history of an ascending aortic aneurysm. He is currently asymptomatic. He is quite involved in his health care. He has the actual CD disks of his CT scans from February and August of this year, when his CT scans were performed. I went over these pictures with him and his wife. There is no change in his 4.2cm ascending aortic aneurysm from February to August of this year. He does have some coronary calcification and I pointed this out to him.



He has had a 2D echocardiogram scheduled by Dr. Tom Smith. This did not show any significant valvular abnormalities. He is currently asymptomatic, does not have any symptoms of heart failure or coronary disease. I recommend repeating his CT scan in one year. I will schedule this, as well as an appointment for him to follow up in my office.

This was from a letter to a referring physician after the post op period was over. There is nothing but the Letter.
I cant find enough in here to bill thought maybe somone else could offer insight.
Thank You:confused:
 
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