Wiki incomplete exams

[laura vangroningen]

Not sure how to code the following situations....

situation 1: Patient has Vital Signs taken and recorded, medication information entered into their medical record, allergy info entered etc. the patient walks out before the dr. enters the room for the exam

situation 2: same as above, and in addition CLIA tests are also done and recorded before patient walks out - prior to dr's exam.

any suggestions?

thanks

 

[shirleyharris]

Shirley CPC, CPMA

Hi Laura,

New patient or established?

 

[rthames052006]

face to face?

Not sure how to code the following situations....

situation 1: Patient has Vital Signs taken and recorded, medication information entered into their medical record, allergy info entered etc. the patient walks out before the dr. enters the room for the exam

situation 2: same as above, and in addition CLIA tests are also done and recorded before patient walks out - prior to dr's exam.

any suggestions?

thanks

In either situation... was there a face to face w/ doctor and patient. If not then there is nothing to bill. There must be a face to face between provider and patient in order to bill.

 

[eescalante]

Assuming these are established patients -

In situation 1 nothing is billable.

In situation 2 you can bill for the CLIA test only, not any E&M codes. UNLESS the nurse also did an evaluation and management service which is recorded in the chart (more than just vitals taken) in which case you can bill a level 1 established patient visit (99211).

See this link for when it is appropriate for a nurse visit to be billed as a 99211 -http://www.medscape.com/viewarticle/481337

 

[dristau]

I can't pass the exam

I have tried to take the exam for the 3rd time and I can't seem to pass the thing. I don't know what I'm doing so wrong. I don't know what to do? Does anyone have any suggestions for me?

Should I be marking/highlighing in my CPT or ICD-9 book? I will take any suggestions anyone might have for me. I feel rushed always when I take it.