Wiki sore throat-complication or not?

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kmdnine

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I am facing a dilemma here. I coded a 99211 nurse visit for a sore throat. The nurse did a rapid strep test and mentioned in her note that the patient was concerned about decreased fetal movements, so she did a US which showed normal gestation. I was called on an audit because I put a chapter 11 code in front of the pharyngitis code. The auditor's logic is that a nurse isn't qualified to say that the pregnancy is incidental to the sore throat, therefore a chapter 11 code shouldn't be used. I can't find anything that addresses this type of situation. Help!
 
If this was an RN, this cannot be a visit. The RN cannot see a patient for a new problem and diagnose and treat it, and it cannot be a 99211. For an RN to charge a visit as a 99211 it must be a follow up visit for an established plan of care for an establish problem. If this had been a provider encounter you would use the 648.93 code first listed as it is not stated that the pregnancy is incidental so the V22.2 is inappropriate.
 
I think I see where the confusion is

They are not new patients to the practice, but it is a new problem. They haven't been seen by anybody yet except a nurse, who usually does a rapid strep test and hands it off to the doctor. I was unaware that they can't bill a 99211 for these, and that's where the problem lies. Thanks for your input!
 
OB coding is unique in that the provider MUST document that the the complaint (in this case "sore throat") did NOT complicate the pregnancy. In the I10 book you will find this guidline under "Chapter 15: Pregnancy, Childbirth and the Puerperium" section a "General Rules for Obstetric cases", subsection 1. Codes from chapter 15 and sequencing priority. (This is page 60 in my AAPC book)

...."It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy"

In this case, with regard to the ICD code, the provider is the RN, who would need to state explicity the sore throat is not affecting the pregnancy. So your first issues is that the provider, whether it be an RN, PA, MD or whatever, regardless of the CPT code, needs to be EXPLICT in documenting whether the complaint is affecting the pregnancy or not.

Plus, the CPT code, as mentioned above has issues. Therefore, there was a double whammy with the coding of this visit.
 
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