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Examination HELP!!

  1. #1
    Default Examination HELP!!
    Exam Training Packages
    I'm not sure what to do in this situation and really need some advice.
    My physician seen a patient in the hospital did a comprehensive HPI and MDM but was not able to perform a cardiology exam: my phydician stated the below on his report:

    "Because of religious reasons the husband refuses to allow any males to examine his wife. He did allow me to place my stethoscope on her chest and I did not hear any pericardial friction rub".

    How do I code this?

    Many thanks in advance.

  2. #2
    Rose City (Portland, Oregon)
    It depends on if this is a subsequent hospital visit or initial/consult. Because of the comp history, I'll assume that it is an initial/consult. If it is an initial, your option is to bill based upon time or 99499 (unlisted E&M code) or use 99231-99233 (using 2 of 3 for history/mdm). If it is a consult, your option is 99251 (one exam was done) or to bill based upon time.

    Good luck.


  3. #3
    Thanks Erin for your reply this is very helful

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