Referral to another facility for surgical treatment

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Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Fri Sep 15, 2017 2:27 pm

If a urologist is going to refer patient to a facility that does a procedure that he does not do (for a problem he has been treating already), can this be a decision for surgery. Pt. decided to have a RALP. Patient has DM that is treated by his primary and is only addressed in the past medical history section by this physician. If he gets credit on the risk table for decision for surgery, would he get credit for the patient being a diabetic as an identified risk factor. Physician wants to charge 99214. He states in his impression: 71 yo male with Gleason 6/7 disease CaP. Pt. wishes to proceed to RALP. Radiation therapy discussed. Will refer to XXXXXXXXX for RALP. If unable to refer, will schedule open RRP with PLND.

HPI states: Pt. here for f/u. Pt. was seen by XRT and pt and daughter wish to proceed with surgery. She does not have anyone to take the pt to all the XRT treatments. Risks and benefits of both treatments explained. Risks of incontinence explained to the patient. Pt feeling well at present. No bone pain. Bone scan and CT scan from 2/24/17 were both negative for metastatic disease.

How many elements can be found in the HPI? The bone scan and CT scan were discussed at the 8/14/17 visit which is recalled on this note along with 1/17, 2/17 and 4/17 HPI notes.
Exam is 5 systems with none in detail (EPF).
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
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Thu Sep 21, 2017 10:47 am

Answered in line for clarity:

If a urologist is going to refer patient to a facility that does a procedure that he does not do (for a problem he has been treating already), can this be a decision for surgery.[Reply] Well, when scoring the E&M theoretically prior to the surgery you wouldn’t know it wasn’t done- and he did make the decision.

Pt. decided to have a RALP. Patient has DM that is treated by his primary and is only addressed in the past medical history section by this physician. If he gets credit on the risk table for decision for surgery, would he get credit for the patient being a diabetic as an identified risk factor. [Reply] They have to identify there is risk as you don’t know unless they tell you.

Physician wants to charge 99214. He states in his impression: 71 yo male with Gleason 6/7 disease CaP. Pt. wishes to proceed to RALP. Radiation therapy discussed. Will refer to XXXXXXXXX for RALP. If unable to refer, will schedule open RRP with PLND.

HPI states: Pt. here for f/u. Pt. was seen by XRT and pt and daughter wish to proceed with surgery. She does not have anyone to take the pt to all the XRT treatments. Risks and benefits of both treatments explained. Risks of incontinence explained to the patient. Pt feeling well at present. No bone pain. Bone scan and CT scan from 2/24/17 were both negative for metastatic disease.

How many elements can be found in the HPI? [Reply] Quality - The bone scan and CT scan were discussed at the 8/14/17 visit which is recalled on this note along with 1/17, 2/17 and 4/17 HPI notes. Exam is 5 systems with none in detail (EPF).
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