Wiki pre-op consult


Bolingbrook, IL
Best answers
How many HPI elements do you get? Should this be coded to a 99212-99215 because of the 'referred' instead of requested?

pt presents to PCP for consult before surgery.

"Pt referred by ENT for pre-op consultation evaluation. Pt is scheduled to have bilateral myringotomy tubes on Tuesday. Currently has URI symptoms-rhinorrhea and no fever."
This does not appear to be a consult to me, I would use one of the established codes 99212-99215. Hopefully the exam and mdm are better than the history so you won't have to use that as a determining factor. As far as this HPI, I come up with

Assoc signs & symptoms- no fever
Modifying factor-tubes on Tuesday (this is kinda stretching it)

Laura, CPC
3 Hpi

I get:
Duration: Currently
Location: myringotomy tubes, URI
Assoc Symp: rhinorrhea, no fever

The documentation for consultation vs established patient visit is weak. But if you have a written request for consultation I'd be more inclined to let you have the consult.

I concur with Laura ... hope the rest of the documentation is a LOT better than this.

F Tessa Bartels, CPC, CPC-E/M