Wiki Follow up after colonoscopy and hemorrhoid banding.

[cnramsey]

I'm really struggling with this type of visit and what the surgeon is picking for the level 99213.

Status post colonoscopy with polypectomy and hemorrhoid banding. States that hemorrhoids are significantly improved has no pain from this and no bleeding. I reviewed pathology with patient today. Noted to have a appendiceal polyps, cecal polyps and descending polys. All of them were adenomatous polyps. These are all developed over the last 2 years since last colonoscopy. I recommend that we repeat colonoscopy in 2 years since had short interval development of more polyps. Patient agrees with this. We will place patient in a recall file.
Patient can return for hemorrhoid banding in the office as need.

Low Risk Encounter

When reading this I'm leaning towards a 99212.

Or would you work the problem(s) addressed up as 2 self limited or minor problems? 99213
Data reviewed 1 path report 99212
Risk Do I give the surgeon credit for recommending a repeat colonoscopy... Decision regarding surgery with identified patient 99214 or since surgeon documented Low Risk... Would you go with Low risk of morbidity for additional diagnostic testing or treatment since the surgeon is putting the patient on a recall list for colonoscopy in two years 99213?

Crossing my fingers I get a lot of discussion on this one.

Thank you,
Nichole

 

[DFUGET]

I would not code these as a 99214. I would bill this as a level 2. The provider is not ordering any additional testing and only reviewed one lab. I don't see the medical necessity to have the patient return for a follow up office visit either. This information can be given to the patient by the nurse over the phone.