Wiki OV follow up after diagnostic tests

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mmullnix

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When a patient is coming back to the office to review their MRI's or other diagnostic tests, how is this service coded from an auditing stand point. There is no real HPI or Exam so those two components are absent. It appears this was more of a discussion with the patient however, time was not indicated. The plan based on the results of the films is for surgery so this would qualify as moderate complexity medical decision making. Please help. These are the audits that are the most frustrating. It is clear the physician is in need of education but what would be the best approach?

:confused:
 
This is an E&M visit, although it is not billable since you don't have documentation to support it. Next time have the physician document the time spent face to face with the patient and you will be all set.
 
I'm a bit curious about the elements of HPI and Exam you do have. Since you say no "real HPI or exam" it leads me to believe there is some.

All you need is a chief complaint, and 1 element of HPI to go along with your MDM and support a 99212. Or a chief complaint and 1 element of exam plus your MDM will support a 99212 as well. Odds are you would be better off (money wise anyway) billing based on time so I certainly agree with educating the provider to document that in the future but I don't think this visit is a total loss without time.

Laura, CPC, CEMC
 
The physician indicated the purpose of the visit by the chief complaint and indicated an MRI was performed. The rest of his note consisted of the remarks from the Radiologist regarding the MRI and the physician concurring with the read. The physician also made comments based on the images of the MRI. So would this not fall under the review of data and not as part of the HPI? Really the only HPI element was the location and chief complaint. His MDM was of moderate complexity since he is deciding to perform elective surgery.
 
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