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Cancer Risk Assessment Consult

  1. #1
    Default Cancer Risk Assessment Consult
    Medical Coding Books
    I have a patient who is asymptomatic but was sent to us (General Surgery) for a risk assessment consult for breast cancer. She has a family history of breast ca and the MD considers her at high risk for breast cancer. We have a consult request and the letter is sent but since she's not having any issues right now, would this be downgraded to a preventive counseling/risk factor reduction visit (99401)? She's being referred to an oncologist to see if she'd recommend starting her on Tamoxifen. If we can bill a consult, would you consider the MDM straightforward since she's not even sick or would you consider it higher because of the Tamoxifen question? Any insights are much appreciated!


  2. #2
    Milwaukee WI
    Default Can you post the note?
    Can you post the scrubbed note? There are so many questions about a case like this.

    Remember that you can bill a consultation based on time spent in counseling/coordination of care (if it's properly documented).

    F Tessa Bartels, CPC, CEMC

  3. #3
    I'll post it as soon as I get the dictation back. Hopefully by Friday...

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