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Need a refresher in this scenario

  1. Red face Need a refresher in this scenario
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    Hello everyone,

    Ok if a patient comes in for a past history for heart palpitations, but currently is asymptomatic at this point in time. Can the physician bill for 785.1 Palpitations of the heart? His ROS nor the exam does not show that the patient has palpitations.

    Thanks everyone! Much appreciated...


  2. #2
    Columbia, MO
    No you may not use a dx code for a symptom not documented and that is no longer current. You may use a V code for a follow up or maybe drug monitoring. Hard to say without knowing the reason for the visit.

    Debra A. Mitchell, MSPH, CPC-H

  3. Talking
    Thank you Debra for your response. I have been doing this for so long, every now and then my brain goes on vacation. Happy holidays!


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