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double dipping?

  1. #1
    Springfield, Mo
    Default double dipping?
    Medical Coding Books
    A patient requests sx correction of a bunion. The doctor does a detailed exam and explains the SX and the recovery peroid. He codes it as 99214.
    At the end of the visit he instructs the patient to schedule a "surgery consult" at their convenience. When the patient returns, detailed exam is documented, sx is scheduled, release forms are signed etc.
    Again, he codes 99214. Is he taking credit for the MDM twice?
    I appreciate any advice.
    solocoder CPC

  2. Default
    I would definitely say yes, once the decision for surgery is made, it is made. If the patient is coming back to sign consents, this is a preop visit and is non billable. If the surgeon is checking history and mdm all over again, it sounds to me like he is solely doing this to bill. If he ever gets audited all of this money will probably be requested back because there is no medically necessary reason to do this and the decision for surgery has already been made.

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