I’m hoping someone can provide direction
Provider documents
45 minutes spent with patient and his mother, over 50% of which was face to face counselling regarding ETOH use and GI bleeding, and developing a plan of care. Mother is supportive and will help with transportation.
Provider Indicated 99215 ,
Unfortunately no screening tool was used for ETOH ie: AUDIT or DAST
HPI indicated "visit"
provider note(used in place of ROS?) is comprehensive with review of pt history of ETOH abuse ,seizure activity and GI bleed
Exam is comprehensive
I’m just not sure 99215 would be correct since counseling focus was ETOH use,however requirements to bill for 99409 weren’t met
Would appreciate some direction for this dilemma
Is there a different more appropriate code to use ?
dx codes used for visit
Anemia, unspecified type – D64.9 .
History of ETOH abuse – Z87.898 (which sounds more like ETOH dependency)
Seizure disorder – G40.909
Depression with anxiety – F41.8
Provider documents
45 minutes spent with patient and his mother, over 50% of which was face to face counselling regarding ETOH use and GI bleeding, and developing a plan of care. Mother is supportive and will help with transportation.
Provider Indicated 99215 ,
Unfortunately no screening tool was used for ETOH ie: AUDIT or DAST
HPI indicated "visit"
provider note(used in place of ROS?) is comprehensive with review of pt history of ETOH abuse ,seizure activity and GI bleed
Exam is comprehensive
I’m just not sure 99215 would be correct since counseling focus was ETOH use,however requirements to bill for 99409 weren’t met
Would appreciate some direction for this dilemma
Is there a different more appropriate code to use ?
dx codes used for visit
Anemia, unspecified type – D64.9 .
History of ETOH abuse – Z87.898 (which sounds more like ETOH dependency)
Seizure disorder – G40.909
Depression with anxiety – F41.8