Wiki Which E/M code would you use?

[jdibble]

What level E/M would I be able to assign in the following situation:

I am auditing an initial inpatient visit where the doctor was evaluating a 96 year old woman who fell. It was unclear if the patient had syncope or why she fell. The HPI was brief and there was no ROS or PFSH because the patient refused to answer any questions. The doctor noted that past medical records were not available to review. The doctor obtained vitals and noted that pt was agitated, but the patient refused the rest of the exam. The doctor reviewed labs and xrays obtained and ordered more tests for the next day and IV fluids. MDM was moderate.

The doctor billed a 99223. Based on what was documented I cannot even come up with a low level inpatient visit. What level should this be? If a patient is unable to cooperate and answer questions for the HPI and ROS or refuses, can you code a visit higher or do you have to code as is documented?

 

[FTessaBartels]

99499 Unlisted E/M

I would use the 99499 Unlisted E/M and use the Initial Hospital Visit code to set my fee.

This is as per the direction of our Medicare carrier - WPS.

Hope that was helpful.

F Tessa Bartels, CPC, CEMC

 

[jdibble]

It still seems a bit confusing, but what you offered does make sense.

Is there a way that the doc could have documented the encounter better so that an initial inpatient visit would have been met? Any suggestions would be helpful as I have to go back to the doctors and tell them where they are lacking in their documentation and how they can improve what they write.

Thanks!

Jodi Dibble, CPC

 

[FTessaBartels]

You can only document what happened / was done

Well, you can only document what was done or what happened.

Seems to me the doctor did a good job of documenting why he could not complete the history or exam.

Like I said, our Medicare carrier (WPS) specifically directs us to use the unlisted E/M 99499 when unable to complete the history - even when the patient is comatose and no family or other hospital records are available. Other carriers will give you full credit for the history. But I don't know anyone who will automatically give you full credit for the exam.

Unlisted E/M 99499 is the way to go. There's nothing wrong with that.

F Tessa Bartels, CPC, CEMC