Wiki Upcoding day later

[maciccone1206@yahoo.com]

If a patient comes in and is seen by provider and provider billed out a level 3. Patient had croup, fever and positive exposure to Covid 19. The patient is 14 months old and obviously not vaccinated. Provider orders a PCR test. I believe, automatically, that the provider should have billed a 99214. I am reviewing claim the next day for billing and PCR test comes back positive for Covid. Is it appropriate for me to send claim back to provider for review? I believe I can have the provider upcode the visit from day before to 99214 and add dx code Covid 19. Am I correct?

 

[csperoni]

Outpatient E/M levels are based on 2 of 3 elements - problem, data & risk. You are only providing the problem and data. What was the treatment plan?
As presented, your problem is likely level 4, but your data (1 test) is only level 2. Without knowing the risk level, this would be 99212.

 

[maciccone1206@yahoo.com]

It is definitely moderate risk. It’s a 14 month old with 104 fever, croup and at time of visit had positive exposure to COVID 19. Both father and sibling have COVID. The patient’s pcr result came in the next day and the patient tested positive for COVID also. Since the test results came in before the visit was billed, is it okay to add COVID as dx on claim? I believe it is, but I wanted to make sure.

 

[csperoni]

If your question is whether you may add the COVID-19 diagnosis, the answer is yes. I thought your question to be about the level of E/M.

 

[Orthocoderpgu]

I'm going to agree with Christine. This may or may not be a 99214. The key to coding this correctly is the severity of the croup. Was it mild, moderate or severe? And how was it treated? Croup and Covid could really limit the patient's breathing. Was the patient just sent home? OTC meds suggested? Or were steroids given to open the lungs or similar treatment? Without knowing how this was treated, it's not automatically a 99214, but probably is.