Wiki CPT for medication concerns

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kmhall

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This is a worker's comp case. An established patient came in requesting a meeting with the doctor to discuss medication concerns. There was no exam but our doctor did query him about his injury status but the main focus of the visit was his concern over "mixing" medications and the potential side effects. Do any of you know of a CPT code that would be appropriate for something like this or is it even billable to begin with? I'm just not sure. Thanks' for any feedback.
 
If time is documented, you could consider using the counseling codes. It must be documented what was discussed, and that greater than 50% of the time was spent counseling.
 
Thanks' for your response. According to the documentation, I deciphered that more than 50% of the time was spent counseling but it does not actually state that in the notes, nor does it list specific time spent with the patient. I suppose I cannot bill for this at all because all of the required elements are not there. Any other suggestions? Thanks'
 
Unfortunately, if two of the three components are not there (history, exam, MDM) and/or time is not documented, I know of no other options. When coding using the "timed" CPTs, total time has to be docmented. Maybe someone else can suggest something. Sorry. :)
 
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