So, here’s the situation…doctor sees a patient with chronic COPD. Patient comes in with probable sinus infection and bronchospasm and is all over miserable, and it is exacerbating the COPD. Doc puts her on steroids and amoxicillin n the plan. He also gave her a nebulizer during the visit.
Now, here’s the kicker…in the assessment, the doctor mentions NOTHING about any URI or sinus infection or anything. Just exacerbation of COPD. Literally the ONLY diagnosis listed.
Would you give him the -25 modifier on the 99213 for the nebulizer since the diagnosis is only for COPD, which is a chronic and ongoing condition?
Let me hear some thoughts!
Thanks!