Wiki Would this Initial Hospital Visit be billable???

[CC5657]

With the new Initial Hospital Codes, just reading the HPI & ROS, would this hospital (consult) be billable?

Reason for consultation: Chest pain, renal failure, a-fib.

43 yo gentleman with type 2 diabetes on CAPD for end-stage renal failure. He was last discharged for a similar complaint on 1/5/10 & is readmitted in less than 72 hours with recurrence of palpitations & chest pain. He is managed on Toprol digoxin.
ROS: Since his discharge there have been no new intercurrent symptoms, please refer to previous dictation.

There is a complete PFSH.
Opinions???

 

[LLovett]

Without a specific date for the documentation referenced I would not count it. Based on that you only have an EPF history, lowest level for an initial is detailed.

I would either have the provider add the date of the referenced document in order to use the ROS, or code this as a subsequent care.

Laura, CPC, CPMA, CEMC

 

[FTessaBartels]

Check with your carrier

Our carrier (WPS) has instructed that when the documentation does not meet the minimum for 99221 and the patient was, in fact, admitted as an inpatient, we are to code the 99499 Unlisted E/M procedure.

However, I would count the previous dictation because he says the person was discharged on 1-5-10 and is being readmitted within 72 hours. I think that's a clear enough indication of which record to check for the complete history. To be certain this is "audit-proof" however I would have him amend the documentation to include the DOS of that previous H&P.

Hope that helps.

F Tessa Bartels, CPC, CEMC