Dear Coders,
This is a rather lengthy question, so please bear with me. A pt. comes into the Ophthalmologist and a complete eye examination is peformed. A diagnosis of cataracts in both eyes is documentated along with the discussion for cataract surgery. The patient wants to think about the surgery and leaves the office. A week or sometimes a month later, the patient requests another visit with the Ophthalmologist and decides to go ahead with the surgery. What E & M code would be appropriate for this second visit?
CC: F/U Cataracts
HPI: All Bullets completely filled out
Examination: The same as the complete eye exam except the patient has not been dilated again therefore, fundus, optic nerve, post. segment, vitreous have not been documented.
A/P: patient has decided to book the surgery and the a-scan is scheduled. I am not sure if I can give credit for the surgical portion again. As it was given on the previous visit. I know that medical necessity drives a visit and not the amount of bullets completed. I would like to find something in writing one way or the other that will spell it out without question. Thank you in advance for your help.