Wiki Patient passes out/how to code

[chriskhans]

Hello,
We have a patient who came into the office for a routine appointment. All went well, she left, went across the hall to get her labs drawn, then came back to our office to make an appointment. While at the front desk she passed out, hit her head on the counter. We monitored her, vitals were taken etc and she left feeling well.
The doctor is asking about a 99215 because she lost consciousness. Any suggestions are appreciated, as I have never had this happen before.
Thanks!

 

[mitchellde]

You cannot just charge a level 5 because, .. The documentation must meet the level 5 criteria. You can take the documentation from the routine visit and add itmtomthencomlexitynof then syncipal episode and if you get a level 5 then so be it.