E/M doc with CT Quesion
When our physicians are doing their own CT's and X-Rays, they are waiting to bill them out until the patient comes back in for a follow up visit. At that visit, they will put their 'written report or interp' into the E/M documentation. I feel like they overlap the reason for the visit (HPI, ROS, PFSH...) I just feel like they are wanting to bill out higher levels of E/M visits that aren't justified... This example below is how they look and this particular provider wanted to bill out 99213 and 70486. I think 99213 is too high and as for 70486, the original date it was done was Feb. 1 and the follow up was Feb. 11. I would have billed 70486-TC on Feb. 1 and 70486-26 on Feb. 11th... Am I wrong? I really feel like it would be most appropriate to do a separate CT report showing the actual date of the CT, a reason, The actual CT name (CT with or without contrast and location), then the report and their impression/conclusion. Any one else see a problem with this??? Or am I over-reacting?
History of Present Illness
CT Review He presents to discuss sinus CT imaging from last week. He has had a long-standing history of chronic sinusitis and has had a recent acute flare up requiring 2 rounds of antibiotics. He is feeling better now. He has had a trial of chemical cautery in the past without relief. Updated CT imaging was recommended to be compared from May of 2010. He denies nasal drainage or facial pain. He does have a history of trigeminal neuralgia involving the left V1.
lovastatin causes all statins, Statins .
Review of Systems
Constitutional Symptoms: Allergies reviewed. Denies fever.
HEENT: Denies bleeding nose, nasal congestion or nasal discharge.
Weight:249.20 lbs. Height:77.00 inches. BMI: 30. Temperature temporal: 97.40 F
Patient is well-dressed and groomed and appears well in no acute distress, breathing easily.
CT - Sinus Procedure: Pella sinus CT images from 1 February were reviewed personally and were discussed with the patient. Axial and coronal images were available for review as well as those images from May of 2010. The septum appeared fairly straight. There was inferior turbinate hypertrophy which was mild to moderate. The middle turbinates were normally developed. There was moderate mucosal thickening the lining the left maxillary sinus with obstruction of the left osteomeatal complex area. There was opacification of debris in the midportion of the left maxillary sinus. There was progressive mucosal thickening compared to 2010 imaging in the left maxillary sinus. The right maxillary ostiomeatal complex areas patent. There was some patchy mucosal thickening in the left anterior ethmoid cells. No air-fluid levels were seen. There was scant mucosal thickening in the floor of both sphenoid sinuses. The frontal sinuses were patent.
Assessment and Plan
ICD: Other Chronic Sinusitis (473.8)
ICD: Turbinate Hypertrophy (478.0)
We reviewed his imaging together. I demonstrated the progressive changes in the left maxillary sinus. I pointed out the opacified elements which could represent fungal debris or chronic staph infection. I advised him to consider an endoscopic left maxillary antrostomy with removal of tissue in the sinus as well as left anterior ethmoidectomy. We could also consider radiofrequency inferior turbinoplasties at the same time. I discussed the procedures and reviewed a handout with him. We discussed the risks. At this time he would like to consider our discussions as he is not sure if he would like to proceed with surgery. He will need a preoperative clearance for surgery. We will need to consider this past medical history to determine if he is a candidate for a surgery center procedure.
Brooke Bierman, CPC, CPB
Coding & Billing Manager
2014 President AAPC Des Moines Chapter