# New pt consult/office visit with NO exam ??



## LaSeille (Sep 23, 2009)

Surgeon wants to bill new patient consults and new patient office visits without doing exams.

Scenario:  Patient goes to primary physician for pain in lower abdomen.  Primary phys orders bloodwork and x-rays.  X-rays shows suspicious looking area in region of colon.  Primary phys sends patient for Colonoscopy.  Colonscopy biopsy reveals cancer of colon.  Primary phys sends patient to surgeon with all of the x-rays and reports.  The surgeon enters the exam room, introduces himself to patient, reviews x-rays, reports and paperwork filled out by patient upon his arrival to office (ie: usual new patient paperwork that includes patient checking off his medical and surgical history, family/social history, signs/symptoms, etc.).   The the surgeon states he agrees that surgery is needed based on the findings of the tests and schedules the patient for surgery.  An exam is NOT performed on the patient.

And NO, time/discussion is not documented so we cannot bill using the time parameters either.

Can a new patient consult or new patient visit be coded/billed for this?

Comments??


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## mitchellde (Sep 23, 2009)

Does he document even the basic constitutional, such as mood, affect, vital signs, etc?  This would at the least get a focused exam which gets you a level 1 visit.  Otherwise I do not see how you will be able to charge a visit unless you use the unlisted code.


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## FTessaBartels (Sep 25, 2009)

*99499*

I'm not sure you could even claim a problem-focused exam for general appearance, as the "problem" is really the colon cancer ... He'd have to at least state something about the abdomen being soft and nontender to get a problem-focused exam in my book. The only option I see is the unlisted E/M 99499.

I wonder if he's doing more than he is documenting. Does he realize the kind of money he is leaving on the table? I had a surgeon like that once ... I talked till I was blue in the face. I actually shadowed him in clinic one day. I KNOW he examined the patient because I was THERE; he just didn't want to bother to document it. 

More importantly, if he really is NOT examining the patient, does he realize the kind of RISK he's exposing himself to if he runs into problem with the surgery?

This is just not a good practice at all.

F Tessa Bartels, CPC, CEMC


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## rthames052006 (Sep 25, 2009)

I'd say you cannot bill a new pt because you must have 3 of 3 key components and if there is no exam it cannot be billed, I'd say use the unlisted 99499 code.






LaSeille said:


> Surgeon wants to bill new patient consults and new patient office visits without doing exams.
> 
> Scenario:  Patient goes to primary physician for pain in lower abdomen.  Primary phys orders bloodwork and x-rays.  X-rays shows suspicious looking area in region of colon.  Primary phys sends patient for Colonoscopy.  Colonscopy biopsy reveals cancer of colon.  Primary phys sends patient to surgeon with all of the x-rays and reports.  The surgeon enters the exam room, introduces himself to patient, reviews x-rays, reports and paperwork filled out by patient upon his arrival to office (ie: usual new patient paperwork that includes patient checking off his medical and surgical history, family/social history, signs/symptoms, etc.).   The the surgeon states he agrees that surgery is needed based on the findings of the tests and schedules the patient for surgery.  An exam is NOT performed on the patient.
> 
> ...


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## LaSeille (Sep 27, 2009)

Seems that shadowing him in clinic was the best idea!   He DOES do an exam.  With enough to get him a level 3 most of the time!   He just doesn't document!   So, I solved the problem.  We had a discussion about it and I designed a new documentation form for him to use during clinics.  Thanks for everyone's input!


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## FTessaBartels (Sep 28, 2009)

*Way to go!*

Way to problem-solve LaSeille!  I hope that doctor realizes what a gem he has in you.

F Tessa Bartels, CPC, CEMC


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## mitchellde (Sep 28, 2009)

I second that!  Bravo!!!


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