Question

1. Mr. Lee became ill on Saturday morning. He presents to the Emergency Department where Dr. Fuller, a PCP, was providing coverage in the ED at the time because an ED physician was not available. Dr. Fuller took Mr. Lee’s history, performed an examination and wrote him a prescription. Mr. Lee did not see any of the ED physicians. Should Dr. Fuller’s services be reported as outpatient visit (99201-99215) or an ER visit (99281-99285)?

2. Dr. Davis (an internist) “admitted” Mrs. Partridge to observation and asked Dr. George (a neurologist) to consult on the case (the request was documented in Mrs. Partridge’s medical record by Dr. George). That same day Dr. George took Mrs. Partridge’s history, performed and examination and ordered medication for her from the hospital pharmacy. Dr. George dictated a consultant’s report which was immediately place in the patients chart. Should Dr. George’s encounter be coded as initial observation care (99218-99220), an outpatient consultation (99241-99245), or an inpatient consultation (99251-99255)?

Answer 1

SOLUTION:

• Dr. Fuller's services can be reported as outpatient visit because he is a Primary care physician(PCP),whose general duties are treating common minor ailments such as headache,common cold,back pain etc,.He may also involved in making differential diagnosis that is making diagnosis based on the symptoms and history of the patient.Since Mr.Lee became ill , a PCP physician could treat the ailment and make a proper diagnosis,it is coded as an outpatient visit(99201-99215) not an Emergency visit.
• Dr.George's encounter can be coded as initial observation care(99218-99220), since Dr. George had visited the patient,collected history,performed physical examination and prescribed medications during observation status of the patient.
• (Inpatient consulatation:Generally it involves services provided to an inpatient by a doctor which is requested by an another doctor.
• Outpatient consultation: Basically it refers to the services provided to the patient who visits the doctor for management and leaves once he or she recieived the treatment)