Wiki Dx code or ov code???

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BRENDA28

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Darien, IL
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Does anybody know how this should be billed?

Patient come in for a works clearance.. Patient was able to work in ceratin period of time. Our doctors never treated patient for this contion...

Paient had a neck surgery.. Which we never treated...

And he came in he need clearance... How do i code this??
 
I think I understand what you're asking.

Does the patient need to see the provider so that the provider can assess whether or not the patient is ready to go back to work? The surgeon who performed the surgery can't/won't do this?

There are a few ways to do this but several questions come to mind. Is this a workers comp injury? Is the employer requesting this evaluation? If so, you could use a consultation code with modifier 32 (mandated service). If not, probably a regular E/M code. I would probably use a V code for the dx but it may help to provide a little more information.
 
Depending on the reason for the exam and what is documented you can also use code 99456. We use this when an employer is requesting the exam and wants an "outside" opinion.

This is an extensive exam though, and typically when my providers perform this, I will see a 6 page note. They need to have the complete history of the injury, the exam, explanation of what the patient's capabilities are and on going treatment, if any, complete any required certificates/documents and then the report.
 
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