• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki pre-op consult

Create Wiki
R

renifejn

Guru
Messages
208
Location
Bolingbrook, IL
Best answers
0
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

Location-URI-rhinorrhea
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
 
You must log in or register to reply here.
Top