dballard2004
True Blue
I need your advice on how to bill, code and document for a patient that two doctors saw today. She was initially seen for a complaint regarding her hand; she was assessed by Dr. A who also administered a Tetanus immunization. The employee was discharged but returned a few moments later with complaints of difficulty breathing. She was brought back in, Dr.A discussed her symptoms regarding the new complaint. We determined it may have been a reaction to the Tetanus immunization. Dr. B administered Benadryl and monitored her for approximately 1 to 1 ½ hrs. Dr. B then re-assessed her, ensured that her vitals were stable and her respiratory complaints had resolved and then she was discharged.
My questions are –
How do two providers document their individual assessments on one patient?
Should we do two separate notes/appointments?
Could we use two separate E/M codes?
What ICD-9-CM codes can we use here? Would we use an E-code for the reaction?
Thanks in advance for all help.
My questions are –
How do two providers document their individual assessments on one patient?
Should we do two separate notes/appointments?
Could we use two separate E/M codes?
What ICD-9-CM codes can we use here? Would we use an E-code for the reaction?
Thanks in advance for all help.