Wiki Attempted Consult

[knperry]

Hello!

My provider was called to do a in patient consult but was not able to finish due to the pt refusing medications and treatment. Can this still be billed and what code should be used? Please see notes below:

History of present illness: this is a 70 year Caucasian man, who was hospitalized 1st at Holmes regional medical center then at kindred hospital, for sepsis, right lower lobe pneumonia, metabolic encephalopathy, end-stage renal disease on peritoneal dialysis, chronic hypo-tension, symptomatic bradycardia, pacemaker implant, right BKA, left ft ulcers. The patient is refusing medications and treatment at this time. I have attempted to evaluate the patient but due to the patient's explicit refusal the family agreed with not to go forward with the evaluation and I have abandoned to proceed. I understand there is as scheduled family meeting with palliative care for today this afternoon. If I could be of any help please do not hesitate to call me. Unfortunately, at this point I cannot do any further intervention.

Any feedback would be greatly appreciated!

Thanks

 

[Pathos]

If there is enough appropriate documentation for a History, Exam and MDM, I don't see why your provider couldn't bill insurance for the level supported by documentation.

Alternatively, you could bill for time, if the documentation requirements are met. I had one instance were one of our providers spent a good amount of time with a patient, who then left during counseling and coordination of care. We billed based on time for that visit.

And no, you can't append Modifier 52 on an E/M (yes, I checked).

 

[knperry]

Thank you