melheffley
Networker
I need some serious help in coding pessary change e/m codes. These are just straight changes, no fitting or new devices. I don't think we are capturing the information needed in the notes and need to explain this to the provider. Below is an example of a note by the doctor:
[Patient Name] is a 82 year old white femail, G3P3 who presents for a pessary change. She desires a pessary as her means of controlling her symptoms of prolapse. She understands the care needed for a pessary and desires to proceed. Alternative treatment options have been discussed at length and the patient voices an understanding of each option.
Procedure
The patient was placed in the dorsal lithotomy position. Examination identifies Grade II cystocele and Grade III uterine prolapse. A #3 ring with support pessary was fitted without difficulty. The patient subsequently ambulated, voided and performed valsalva maneuvers without dislodging the pessary and without discomfort. Care instructions were provided. Patient was discharged to home in stable condition.
Assesment
Uterine Prolapse 618.1
Cystocele 618.01
Plan
Premarin Vaginal Cream 0.625mg/g
Disp: 1 tube with 3 refills
Return in 3 months (sooner if problems)
Typically with this documentation only provided, our doctor would code this with a 99213. However, for this patient he states it is a 99214 because "it took longer".
I'm not sure how to prove a 99213 let alone a 99214 for this. If he is using the amount of time spent as a factor, shouldn't he have to state the amount of time spent with the patinet and possibly the to and from times?
Can anyone help me out with this? and with an explination that I can provide the doctor??
Thank you in advance for any help I might get!!
[Patient Name] is a 82 year old white femail, G3P3 who presents for a pessary change. She desires a pessary as her means of controlling her symptoms of prolapse. She understands the care needed for a pessary and desires to proceed. Alternative treatment options have been discussed at length and the patient voices an understanding of each option.
Procedure
The patient was placed in the dorsal lithotomy position. Examination identifies Grade II cystocele and Grade III uterine prolapse. A #3 ring with support pessary was fitted without difficulty. The patient subsequently ambulated, voided and performed valsalva maneuvers without dislodging the pessary and without discomfort. Care instructions were provided. Patient was discharged to home in stable condition.
Assesment
Uterine Prolapse 618.1
Cystocele 618.01
Plan
Premarin Vaginal Cream 0.625mg/g
Disp: 1 tube with 3 refills
Return in 3 months (sooner if problems)
Typically with this documentation only provided, our doctor would code this with a 99213. However, for this patient he states it is a 99214 because "it took longer".
I'm not sure how to prove a 99213 let alone a 99214 for this. If he is using the amount of time spent as a factor, shouldn't he have to state the amount of time spent with the patinet and possibly the to and from times?
Can anyone help me out with this? and with an explination that I can provide the doctor??
Thank you in advance for any help I might get!!