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E & m coding (i'm confused)

  1. Default E & m coding (i'm confused)
    Medical Coding Books
    I have a provider that had seen a new consult hosp pt for acute renal failure (ARF), The provider marked 99255 for this visit, however the pt was intubated & sedated so therefor was unable to do the ROS, I know that the chief complaint (ARF) can be used in other components so I wonder do I have to use this on the ROS because if I do that would put me at expanded verses comprehensive, even though she has plenty on the examination and the medical decision making. since we have to code to the highest level of service that is documented & then the lowest element will then determine the overall history level. pls can anyone help me out on this one???? Ca

  2. #2
    New Braunfels and San Antonio
    Default Consult codes
    HI confused,

    as this is a consult code the ROS of the renal system ... expecting that is what she was seen for.... should be listed as your are not billing CMS... the guidlines you may use depend on standard billing practices for your company. are you using 95 or 97? Find the cheat sheet online for the guideline you are using and then you will know what ROS is applicable... ie ROS not address as patient was in coma? ROS not address as pt is mut and hands are strapped? are other possiblities?? send a quey when you find what is needed... Of course if this is a Medicare PT no consults allowed :-)

  3. Default billing IP consult code
    I'm still a bit confused, I'm not sure if were using 95 or 97, how would I go obtaining this info?, The reason for the consult is ARF & the ROS was not done because the pt was admitted for abd pain & dx'd with pancreatitis 2nd to alcoholism & then developed resp distress then moved to the unit, was intubated & sedated & this is the reason the ROS didn't get done, so I guess my overall ? is that do I have to count the ARF on my ROS or can I count the chief complaint, Hpi and pfsh as my 3 key components and not count the ROS as it would make my level of service much lower??? I THANK YOU so much for your help Ca

  4. #4
    Default E/M
    Why wouldn't you caveat the H&P due to the patient being intubated and sedated?

  5. #5
    Daytona Beach, FL
    If it is clearly documented that a review of systems could not be obtained because the patient was intubated and sedated, then you can give credit for a comprehensive history if that meets the medical necessity of the visit.
    Jodi Dibble, CPC

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