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Wiki Sent to ER...99215?

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chetubig001

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Fair Oaks, CA
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If a patient comes in for severe abdominal pain and is unable to stand upright, the Dr. is unalbe to complete a ROS and Exam due to the severity of the patients condition and send them to the ER. Would that be automatically a 99215? Even if they did not spend much time with the patient and are lacking a comprehensinve History and Exam?
 
I would not code as a 99215!!! This would be a no charge visit since the patient was sent directly to the ER. The doctor would act as the admitting physician if the patient is admitted. The doctor would dictate the H & P. :)
 
With no ROS, the best you can get for history is problem focused. With no physical exam, the history and medical decision making are the 2 elements you have to code an established patient visit. That puts you at a 99212 at best. I would hold out and see if my doctor admits. Then you can charge the initial inpatient level that best fits his H&P.

Michele R. Hayes, CPC, CPMA, CEMC, CGIC
 
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