Kennedyjo13
New
I have a situation where a provider is wondering if there should be an additional charge with a preventative wellness visit. I have a 99396, only.
Provider says they also had CDM as well as a Preop during the visit. The patient did have 4 labs completed during the visit with their current, stable chronic diseases as primary, all with comments saying unremarkable, labs look great, no concerns.
Provider said they did medication management, but really just stated that the current medications appear to be working (no changes, or updates). And, in a few sentences within the same note, said that the patient is cleared for their scheduled, routine colonoscopy. No risks identified, no family or personal history, no labs ordered specifically for preop. A preventative colonoscopy.
Should there be an additional level coded with this? Thoughts?
(This is RHC and do not use the consultation codes, preop is coded as 99213, etc.)
Provider says they also had CDM as well as a Preop during the visit. The patient did have 4 labs completed during the visit with their current, stable chronic diseases as primary, all with comments saying unremarkable, labs look great, no concerns.
Provider said they did medication management, but really just stated that the current medications appear to be working (no changes, or updates). And, in a few sentences within the same note, said that the patient is cleared for their scheduled, routine colonoscopy. No risks identified, no family or personal history, no labs ordered specifically for preop. A preventative colonoscopy.
Should there be an additional level coded with this? Thoughts?
(This is RHC and do not use the consultation codes, preop is coded as 99213, etc.)
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