stockish; everydayplus / shutterstock.com
Scenario A
A 67-year-old, female Medicare patient diagnosed with rheumatoid arthritis, previously without rheumatoid factor, calls the rheumatologist’s office to get an update on the lab tests taken when she was last seen in the office two weeks before. The patient was tested for C-reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) and erythrocyte sedimentation rate (ESR). She speaks with the nurse for 10 minutes concerning her lab results.
The nurse informs her that her CRP is 0.8 mg/dL, which is within normal limits; her RF is elevated at 30 U/mL; her anti-CCP is 17 U/mL, which is within normal limits; and her ESR is 22 mm/h, also within normal limits. Because the patient’s RF is now elevated, her rheumatologist requests she make an appointment within a week.
The nurse schedules a visit for the next day.
Scenario B
A 67-year-old, female Medicare patient diagnosed with rheumatoid arthritis, previously without rheumatoid factor, calls the rheumatologist’s office to get an update on the lab tests taken when she was last seen in the office two weeks before. The patient was tested for CRP, RF, anti-CCP and ESR. She speaks with the nurse for 10 minutes concerning her lab results.
The nurse informs her that all the tests were within normal limits. Her CRP is 8 mL per liter; her RF is 5 U/mL; her anti-CCP is 17 U/mL; and her ESR is 22 mm/h.
The patient does not have any questions and is scheduled for a follow-up visit in six weeks.
Which of these scenarios is billable, and how should it be coded?
Editor’s note: Case vignettes presented in the Coding Corner are created to illustrate questions about coding. They are not intended to represent the full medical record of a case.