ICD-10: M79.1, R21, R53.83, L65.9, K13.79, R00.0
This visit can be billed out as a 99245 only if the insurance carrier allows the billing of consultation codes. If the carrier does not allow consult codes, then this visit must be billed as a new patient visit.
Because many outpatient visits lack definitive diagnosis at the time of service, keep in mind that possible, probable, suspected or rule-out problems should not be coded until a definitive diagnosis has been made. In this case, it is acceptable for providers and coders to code the signs and symptoms to meet outpatient coding guidelines.
History: The HPI was extended, the ROS was complete, and all elements of the past, family and/or social history (PFSH) were documented, making the history comprehensive in level.
Examination: Using the 1995 documentation guidelines, eight organ systems were examined:
- Constitutional;
- Ear, nose, mouth and throat;
- Cardiovascular;
- Respiratory;
- Gastrointestinal;
- Musculoskeletal;
- Skin; and
- Neurological.
The documentation for the exam supports a comprehensive level.
Medical decision making: The number of diagnoses or treatment options, and new problems with additional work-up plan make this section of the MDM extensive. The amount of data and/or complexity of data to be reviewed contain orders for labs and medical test (ECG); these orders make this section level low. The level of risk of complications and/or morbidity or mortality is of a high level for the acute or chronic illness and pose a threat to life. This makes the MDM a high-complexity level for this visit.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.
