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Margaret Posted Fri 14th of January, 2011 16:03:11 PM

Not sure how to code this office visit, and need some advice.

The patient came in to see doc in December when the decision to perform a parathyroidectomy was made. The patient subsequently fell and fractured two ribs and had a lung contusion. We saw the patient back following this fall to decide whether or not surgery would still take place. Doc decided to hold off surgery until Feb. The patient has Medicare. Is this visit billable, even though the decision for surgery was made in December 2010?

Thanks in advance for your help!

SuperCoder Answered Mon 17th of January, 2011 03:46:56 AM

If the visit was solely intended re-schedule for the already planned surgery in the present context and not to evaluate for fractured ribs, then it should not be billed.

Had there been any documentation of care taken by the physician with reference to current problem, then we can only bill the patient, which is not the case here.

Margaret Posted Mon 17th of January, 2011 16:40:08 PM

Thanks Sanjit, that it was I initially thought, but just wanted to be sure.

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