[QUOTE=dballard2004;19168]I need your advice on how to bill, code and document for a patient that two doctors saw today. She was initially seen for a complaint regarding her hand; she was assessed by Dr. A who also administered a Tetanus immunization. The employee was discharged but returned a few moments later with complaints of difficulty breathing. She was brought back in, Dr.A discussed her symptoms regarding the new complaint. We determined it may have been a reaction to the Tetanus immunization. Dr. B administered Benadryl and monitored her for approximately 1 to 1 Â½ hrs. Dr. B then re-assessed her, ensured that her vitals were stable and her respiratory complaints had resolved and then she was discharged.
My questions are â€“
How do two providers document their individual assessments on one patient Easily, they each dictate their own notes regarding the care they provided to the patient
Should we do two separate notes/appointments? Yes, two separate notes - each provider should document their care given to the patient
Could we use two separate E/M codes? yes, two separate E/M codes, each doctors documentation should support their service and stand alone. Are the docs same specialty? You'll need to modifiy the office visit accordingly if so.
What ICD-9-CM codes can we use here? Would we use an E-code for the reaction? I'd use the dx of why they came in to see the first doc, whatever the hand problem was, along with the tetanus and administration of it with a .25 modifier on that visit - for the second provider I'd code out adverse reaction to med (given correctly, correct amount) - we don't use Ecodes in our facility at this time but if you use them, it won't hurt to add it, and don't forget the .25 modifier on this E/M due to two office visits same day
Thanks in advance for all help.
well, that's my "blue" opinion anyway!
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