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pre-op consult

  1. Default pre-op consult
    Medical Coding Books
    How many HPI elements do you get? Should this be coded to a 99212-99215 because of the 'referred' instead of requested?

    pt presents to PCP for consult before surgery.

    "Pt referred by ENT for pre-op consultation evaluation. Pt is scheduled to have bilateral myringotomy tubes on Tuesday. Currently has URI symptoms-rhinorrhea and no fever."

  2. #2
    This does not appear to be a consult to me, I would use one of the established codes 99212-99215. Hopefully the exam and mdm are better than the history so you won't have to use that as a determining factor. As far as this HPI, I come up with

    Assoc signs & symptoms- no fever
    Modifying factor-tubes on Tuesday (this is kinda stretching it)

    Laura, CPC

  3. #3
    Milwaukee WI
    Default 3 Hpi
    I get:
    Duration: Currently
    Location: myringotomy tubes, URI
    Assoc Symp: rhinorrhea, no fever

    The documentation for consultation vs established patient visit is weak. But if you have a written request for consultation I'd be more inclined to let you have the consult.

    I concur with Laura ... hope the rest of the documentation is a LOT better than this.

    F Tessa Bartels, CPC, CPC-E/M

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