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Consultation of abnormal LFTs

Apurva Posted Fri 08th of November, 2019 03:33:31 AM
what the requirements are for billing visits regarding LFTs They repeatedly recommend to down code these visits because there is no documentation of   • Location. • Quality. • Severity. ... • Duration. ... • Timing. ... • Context. ... • Modifying factors. ... • Associated signs and symptoms However, these components are not all applicable to evaluation of abnormal LFTs. Please advise.
SuperCoder Answered Mon 11th of November, 2019 06:27:05 AM

Hi,

 

Sometimes it's test results that prompt a patient visit, not pain or even a complaint. A patient may come to a physician because he has abnormal test results.

 

It can be a challenge to obtain four out of eight elements of the history of present illness (HPI) when the patient comes in with abnormal LFTs, for example.


The patient's medical decision-making is complex, but the doctor can't obtain a level-four visit without full HPI documentation. And if the patient's history has only 1-3 elements, the coder must downcode these cases.

 

Please also check below link for better understanding:

https://www.supercoder.com/coding-newsletters/my-medicare-compliance-reimbursement-alert/physicians-you-can-still-bill-a-level-4-em-visit-for-a-patient-with-abnormal-test-results-121731-article

 

Thanks

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