Wiki Multiple visits, same week

[AprilSueMadison]

Pt came in on 1-27 with an infection. Workup was done and we billed out a 99212.

Same pt came in 1-29 for a followup. We did a workup on the infection site, prescribed new meds and sent her on her way. The notes justify an office visit...BUT, is it normal for doctors to charge office visits in a situation like this? Normally we don't, but the doctor is asking me to find out what others do.

Thank you!

 

[LLovett]

Yes, normally you would charge for both visits in this situation. The only time you wouldn't charge would be if you were dealing with a global period, which E/M does not have.

I am a bit stumped at how you could have a new problem with work up meds and a necessary re-eval 2 days later that required additional work up and change in meds and only have supported a 99212 for the first visit.

Laura, CPC, CPMA, CEMC

 

[MnTwins29]

I could see that scenario. Without the benefit of reading the record, on 1/27 it could have been very well one of those "take two aspirin and call me in the morning" types of visits. Just examined the affected area, take an OTC or RICE, whatever for SF MDM. Then, when it's not working and it gets worse, pt comes back two days later, saying it's not working....

 

[AprilSueMadison]

I agree that the code should have been higher originally. The problem I'm facing is that I can't get enough documentation out of them sometimes to support a higher code. Had they given me more of a HPI, maybe duration or what the patient had already tried...you know, things like that....we would absolutely have had a higher code. Unfortunately, they didn't write down a lot other than the patient was experiencing red and hot to the touch spot on their elbow.

I figured others would charge in this situation, the doctors just are really lenient on our patients since so many of them are elderly so they would normally just mark it as a followup and not charge. Thank you!