Urology Coding Alert

Question: A patient injected himself with a silicon agent into the scrotum. We were not able to obtain a medical history, as he is intubated for presumed drug overdose. Our physician documented review of systems, family/social history, labs from his hospital chart, his assessment, and a treatment plan. Do I have enough information to bill a consult?

Vermont Subscriber

Answer: A complete history includes three components: HPI, ROS, and PFSH. You can mention the history as unobtainable and include the reason; then it will be considered as the highest level (comprehensive). In your situation, the reason for being unable to obtain all information would be the patient’s unconsciousness.

Lab work, assessments, and treatment plans are considered under the umbrella of medical decision making (MDM). The physical examination must also be mentioned in the physician’s report in order to reach the designation of a level one service.