Is this office visit billable??

coder25

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Not sure how to code this office visit, and need some advice.

The patient came in to see doc in December when the decision to perform a parathyroidectomy was made. The patient subsequently fell and fractured two ribs and had a lung contusion. We saw the patient back following this fall to decide whether or not surgery would still take place. Doc decided to hold off surgery until Feb. The patient has Medicare. Is this visit billable, even though the decision for surgery was made in December 2010?

Thanks in advance for your help!
 
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Milwaukee WI
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Hard to tell without seeing the actual note

It's hard to tell without seeing the actual note, but I could envision a scenario where it would be medically necessary to see the patient again to determine what procedure and whether to schedule.

As usual, it all depends on the documentation.

F Tessa Bartels, CPC, CEMC
 
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