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Wiki Pain Pump Adjustment & Office Visit

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lcole7465

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I'm in need of a 2nd opinion - the discussion in my office is that an office visit should be billed with the following. The provider did a pain pump adjustment (CPT 62368), he also had a lengthy discussion with the patient about having the pump removed because the patient wasn't getting any relief from the pump. The note reads as follows;

"The patient is here because she does not want to continue with the pump, It is not helping her that much because it's causing a lot of pain into her abdominal wall and is also flipping under the skin and wants the pump removed. I had a very lengthy discussion with the patient, the patient wants the pump completely out. I gave several options but wants the pump out. I cut the pump by 50% and we will see the patient next week I will put the pump on minimal rate and we will remove it."

We only billed for the adjustment. The removal was performed after the second adjustment to reduce the pump.

Thank you
 
I would call that an office visit, with modifier 25. Instead of "lengthy", he should document how much time he spent and what the options were that he discussed.
 
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