Wiki Pt. same day office visit

[rribbeck]

Parents brought there infant into the office for fever, concurrent URI symptoms. Associated symptoms include cough, decreased appetite, decreased fluid intake, decreased urine output and nasal drainage. Dx was Acute JRI. Provider instructed parents supportive care including suctioning w/saline, elevate head of bed, use of a humidifier or steam from a shower. Return to clinic if continues worsen. About 1.5 hours later parents came back with there child stating the child had total seizure time approximately 5 minutes. The child had a fever at this time of 101 degrees pulse ox 92-97% BS 119 lung sounds clear as before, She was post-ictal for awhile. Gave Rectal tylenol 120mg and EMS was contacted to transport to ED for observation. So the question from my provider is can she submit the Dx Simple Febrile Seizure R56.00 on the same visit as the Acute URI even though there was a gap of 1.5 hours between being seen.

Robert Ribbeck
CPC

 

[CShipitz]

In order to have 2 e/m codes on the same day for the same practice, the services have to be completely unrelated, with a modifier 25 on the first e/m. Since was seen for a fever during the first visit, then the documentation for the febrile seizure visit would not be sufficient to qualify as distinct and unrelated. It's not so much the diagnoses being different (which even those are related if fever was mentioned and/or coded on the first one), it's the documentation that will pretty much conclude that it's not unrelated. In a cliff's notes version......"you can't have a febrile seizure if you're not febrile. and she was febrile during the first visit".

 

[AmandaBriggs]

As the previous user stated about not being able to report 2 E/M's on the same DOS by the same provider, an option to consider would be combining the documentation for both visits (as they occurred on the same DOS) and reporting the applicable ICD-10 codes from both notes.