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Coding Dilema

  1. #1
    Overland Park, KS
    Default Coding Dilema
    Medical Coding Books
    Can anyone help with this please? Thanks.

    We had a patient few weeks back that came to the office and the clinic for evaluation of post MVA, 1 day, with hip pain and suspected strain, neck pain with suspected strain, and back pain with suspected strain.. Oh yes incidentally he had elevated BP. He had not had any x-rays for this evaluation, and while the provider was evaluating him, he got a cell call( from the other car involved in the accident ) insurance guy. " Oh can I get a flu shot today?" is also one of his request.

    So from this massive C.C. ( chief complaint), how would be best to document and then code this patient for maximum reimbursement.?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    Default mva & addtl diagnosis
    Are you billing it as a PIC to auto insurance? If so, there would be two seperate charges as long as documentation supports it.

    At our clinic, we inform the patient that if it is billing as a PIC and additional issues are brought up during that visit it could incur an additional office charge. That would be billed to the patients insurance (if any) or self pay.

    If patient is using his insurance and not billing PIC - bill all together to patients personal insurance (not PIC) then again depending on documentation you charge the E/M accordingly. I would list the MVA issues 1st (main reason for being seen) and then the elevated BP and influenza shot as necessary.

  3. #3
    Overland Park, KS
    Thanks so very much for the help!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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