jliving77
Networker
We have a refugee patient whose mother came into the clinic for a visit that was scheduled for her daughter, however since it was to follow up on how her TB treatment is going she didn't think that the child had to come with her. I am copying exactly what he wrote as I don't want to miss something an not get an accurate answer to my question.
"CC: Mother is here for tb medication. She did not bring patient in with her..
History of Present Illness:
Translation phone service utilized for interview.
Mother here - she did not realize that was a scheduled appt. for her daughter so did not bring dtr from school.
Reviewed TB treatment course. Mother reports she started medication in Sept. as soon as it was prescribed. When asked to estimate how many days in total she missed a dose, she replies "zero" without hesitation - reports giving it to her every single day. Finished w/ medication in June. Reports that pt. has been in good health - no cough, fevers, sweats, weight loss.
Physical Examination
Height: 44 (09/20/2013)
Impression & Plan:
1. PPD POSITIVE.
Pt. has satisfactorily completed 9 mo. tx w/ isoniazid for latent TB. Educated mom that pt's TB skin test will remain positive, so she should not have this done in the future. Provided mother w/ letter documenting that pt. had neg. CXR and completed full tx course.
Pt. due for well child exam - mother taken to appt. desk w/ interpreter on phone to schedule appt. for this."
When reading this and checking the E&M section, 99212 requires a problem focused history; exam, and SF medical decision making. I think that it hits the mark for a problem focused hx and SF MDM and the definition goes on to say "typically 10 mins are spent face-to-face with the patient and/OR family".
Am I correct that I can bill this code due to it saying and/OR family?? Or is there a better code to bill for this visit?
Jennifer
"CC: Mother is here for tb medication. She did not bring patient in with her..
History of Present Illness:
Translation phone service utilized for interview.
Mother here - she did not realize that was a scheduled appt. for her daughter so did not bring dtr from school.
Reviewed TB treatment course. Mother reports she started medication in Sept. as soon as it was prescribed. When asked to estimate how many days in total she missed a dose, she replies "zero" without hesitation - reports giving it to her every single day. Finished w/ medication in June. Reports that pt. has been in good health - no cough, fevers, sweats, weight loss.
Physical Examination
Height: 44 (09/20/2013)
Impression & Plan:
1. PPD POSITIVE.
Pt. has satisfactorily completed 9 mo. tx w/ isoniazid for latent TB. Educated mom that pt's TB skin test will remain positive, so she should not have this done in the future. Provided mother w/ letter documenting that pt. had neg. CXR and completed full tx course.
Pt. due for well child exam - mother taken to appt. desk w/ interpreter on phone to schedule appt. for this."
When reading this and checking the E&M section, 99212 requires a problem focused history; exam, and SF medical decision making. I think that it hits the mark for a problem focused hx and SF MDM and the definition goes on to say "typically 10 mins are spent face-to-face with the patient and/OR family".
Am I correct that I can bill this code due to it saying and/OR family?? Or is there a better code to bill for this visit?
Jennifer