jeskla
Networker
Hi Everyone,
Our DO says we should be coding his initial osteoporosis clinic visits with preventative medicine (9938X, 9939X) codes, but he doesn't do an examination. He does a comprehensive history, heavy on the medical decision making, and spends the majority of time counseling the patient. I have been coding by time since he spends more than half of the FTF time counseling/coordination of care. (I make sure he documents the total FTF time and what he counseled on.)
Could I have your guidance on this please? I've already showed him the CPT book description that states " Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender [U]appropriate[/U] history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures. "
He says he doesn't feel the exam is appropriate and the above states appropriate... so its not required since he has deemed it inappropriate.
Our DO says we should be coding his initial osteoporosis clinic visits with preventative medicine (9938X, 9939X) codes, but he doesn't do an examination. He does a comprehensive history, heavy on the medical decision making, and spends the majority of time counseling the patient. I have been coding by time since he spends more than half of the FTF time counseling/coordination of care. (I make sure he documents the total FTF time and what he counseled on.)
Could I have your guidance on this please? I've already showed him the CPT book description that states " Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender [U]appropriate[/U] history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures. "
He says he doesn't feel the exam is appropriate and the above states appropriate... so its not required since he has deemed it inappropriate.