Question

12. Dr. Johnson an internist) saw Ms. Bane. Dr. Johnson suspected a gynecological problem. Dr. Johnson called Dr. Thomas (an OB/GYN) and asked her to evaluate Ms. Bane. There was no written request sent to Dr. Thomas by Dr. Johnson. However, based on Dr. Johnson's verbal request (which was documented by Dr. Thomas and Dr. Johnson in each of their medical records), Dr. Thomas saw Ms. Bane in the office. She took Ms. Bane's history and performed an examination. She then wrote Dr. Johnson and provided him with her opinion regarding Ms. Bane, recommended a course of treatment (which was filed in Ms. Bane's medical record) and thanked him for the referral. Should Dr. Thomas's services in the office be coded as an office visit (99201-99215) or an office consultation (99241-99245)? 13. Same as above except Dr. Thomas also wrote a prescription for Ms. Bane and made a follow-up appointment for Ms. Bane to see her again in three days. Should Dr. Thomas's initial services (not the follow-up visit) be coded as an office visit (99201-99215) or an office consultation (99241-99245)? 14. Same as above. At the conclusion of the follow-up visit, Dr. Thomas wrote Dr. Johnson again providing him with an update on her opinion regarding Ms. Bane. Should Dr. Thomas's follow-up services be coded as an office visit (99211-99215) or an office consultation (99241-99245)? 15. Same as above except a week later Dr. Johnson saw Ms. Bane again. He was concerned that her condition had not cleared up so he called Dr. Thomas and asked her to reevaluate Mrs. Bane and provide an updated opinion. Dr. Thomas documented Dr. Johnson's verbal request and saw Ms. Bane in the office. She took Ms. Bane's history and performed and examination. She then wrote Dr. Johnson and provided him with her updated opinion regarding Ms. Bane and recommended a revised course of treatment. Should Dr. Thomas's services in the office be coded as an office visit (99201-99215) or an office consultation (99241- 99425)?

Answer 1

First of all Dr.Johnson an internist seen the patient which was suspected as gynac issues and reffered to Dr.Thomas gynacologist. When a doctor make a refferal that should be documented in written in case file or in EMR( electronic medical records) . Verbal orders should not entertained. If verbal order taken for emergency then orders should be documented in written with in 24 hours. So better to have electronic medical records so that its a main eveidence as a proof , so better to have services coded which is legal. Its better for doctors also even patient also.