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E/M outpatient visit

  1. Question E/M outpatient visit
    Medical Coding Books
    I'm hoping someone can help.
    Can I bill an established outpatient visit for my gastro doc?
    Here is discharge summary from Short Stay.
    30 year old female pt came in to outpatient short stay for scheduled colonoscopy with rectal bleed and anemia.
    hx of boderline hypertension. On toprol. Pt also has palpitations
    Physical exam done
    bp checked, murmur
    lung: clear
    abdomen: benign
    rectal: negative in office
    labs showed hg & hct of 10 & 31 mcv of 72
    Pt given a screening urine pregancy test which was positive and then a serum pregnancy test done. She was then deemed high risk for iv sedation. Then seen by ob/gyn who recommended not to undergo procedure
    consult: ob/gyn
    Procedure obviously never started and pt was discharged from short stay but doc examed her, ordered test and consult.
    Thanks in advance for any help!!!!

  2. Default
    Your doc provided you with a nicely done Patient Encounter Form and that does qualify for an E&M level. Darlene

  3. #3
    I would say yes - you can bill an outpatient visit. Was this patient previously seen by you doc (or another one in the group)? If so, that would make her an established patient.

  4. Default
    Thanks for your help. I would use the e/m code with a POS of 22 since it was a hospital short stay facility.

  5. #5
    What a way to find out you're pregnant!

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