Wiki What is the code?


Perkasie, PA
Best answers
I requested notes for a new patient office visit from our general surgeon office. These services are coded by the doctors. He chose a 99204 and as shocking as it may be it was denied for medical necessity by Medicare. Here is the note:

I saw your patient in the office today to arrange to have his pacemaker generator changed on 2/29/12. He will be stopping his Coumadin as of today. Our office wil also be contacting you to make sure that you do not need any bridge therapy.

According to the note there is no exam, and no HPI. Is it even possible to achieve a 99201 from this? I just don't see. HELP!!!! Please.
If this is the entire note, I don't see a billable visit here. Medicare will not pay for E/M services within 72 hours of a surgery and consider it bundled into the surgery. If this was not within 72 hours of the surgery, you need a History, Exam and Assessment for MDM. You have documented a CC. There is no time documented so you can't code that way. Your physician should know that a 99204 requires a Complete History, Complete Exam and Moderate MDM. And there should be "Medical Necessity" to do that too. If the patient just needs to have the battery changed, unless the patient has other major medical problems that would complicate the surgical procedure, then the MDM is pretty low. It's a simple outpatient procedure with minimal risk.
72-hour rule not a factor here

The 72-hour rule is part of Medicare's Prospective Payment System and applies to hospital charges. (The 72-hour rule treats outpatient services the same as inpatient serviceswhen those services provided for Medicare patients are within 72 hours of a hospital admission. Those charges are considered to be part of the inpatient services and are to be billed on one claim.)

An office visit, as in the scenario above, would only be bundled if it was the day before or day of a major surgical procedure.

Regardless, I agree the note shown doesn't support any code.