Wiki E&M Coding question

[surgcoder]

A doctor in our office wants to charge a Level 3 new patient visit. The dictation states "the patient has lymphoma, needs a bx of leg lesion and a port placement. He understands risks and benefits and will be scheduled for surgery soon. Please see hospital dictation". Can I use hospital dictation to charge the office visit?

 

[FTessaBartels]

What hospital dictation?

What hospital dictation ... isn't this a new patient?

I have no problem using records that are produced in different systems when it's for the same date of service and accurately reflects the service performed.

Sounds to me as if the doctor just doesn't want to have to dictate a separate H&P for the surgery at the hospital.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[ewinnacott]

I agree the doctor needs to have more documentation than just that. The office visit might be undercoded, so if he does a SOAP or at least give more information on the visit than what he's given already..you might be able to code a 99204/99214.

Hope this helps
Ed