Wiki surgery consult

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solocoder

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When a patient has had a detailed history and exam, doctor recommended surgery, and the patient wants to come back in 2 weeks with their spouse and have the doctor go through the whole process over again, is there any way to justify billing the second visit?
Any thoughts are appreciated :)
 
It would be difficult to justify billing for repeating the history and exam that physician had already done if there was no change in condition between visits, but if the patient feels that they need to ask additional questions or get additional advice in order to make an informed decision about the procedure, then I think that could provide medical necessity for a counseling visit and support billing an E&M code based on time. The key would be the provider's documentation of their assessment of medical necessity of that second visit.
 
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