Wiki Icd-10 cm guideline & cpt

[DhyanPradeep21]

Hi Friends,

Can anyone help me in clearing my doubts.

1. Can i code diagnosis which has mentioned the term "versus".
Example: abdominal pain versus small bowel obstruction.

2. If the patient has encountered for wellness examination for the first time and he is established patient for the physician.
Can we code 99213(established patient office visit) along with 99385(new patient wellness) ?

 

[ksobota]

Regarding #1, I would just code whatever symptoms they're having regarding that visit, i.e. the abdominal pain, gas, etc. Since abd pain is under the signs and symptoms that would be what would be used along with any others they may be dealing with. You don't want to diagnose a patient with a confirmed SBO if he doesn't have one.

For #2, you can bill a separate office visit if they patient is seen for something above and beyond the physical. If the doc only does a physical and evaluates them for chronic conditions and nothing's changed, I wouldn't bill the 9921x. If they were seen for something acute (like bronchitis or an acute injury and extra work specific to that was documented) or extra evaluation regarding a chronic condition (like their meds were significantly changed and extra testing was done for their hypertension) then I would bill the 9921x-25 depending on the documentation.

 

[DhyanPradeep21]

Regarding #1, I would just code whatever symptoms they're having regarding that visit, i.e. the abdominal pain, gas, etc. Since abd pain is under the signs and symptoms that would be what would be used along with any others they may be dealing with. You don't want to diagnose a patient with a confirmed SBO if he doesn't have one.

For #2, you can bill a separate office visit if they patient is seen for something above and beyond the physical. If the doc only does a physical and evaluates them for chronic conditions and nothing's changed, I wouldn't bill the 9921x. If they were seen for something acute (like bronchitis or an acute injury and extra work specific to that was documented) or extra evaluation regarding a chronic condition (like their meds were significantly changed and extra testing was done for their hypertension) then I would bill the 9921x-25 depending on the documentation.

Thanks for your valuable knowledge sharing.