Question

Dr. X asks Dr. Y to look at a 65-year-old male who is in a nursing facility for decubitus ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a detailed history from Dr. X since the patient is unable to provide a history. A detailed exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to the surgical suite for debridement of the ulcerations. Since the patient is unstable at the moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep monitoring the patient until he stabilizes. Written report is documented. What CPT® code is reported?

Answer 1

99253

Step-by-step explanation:

Dr. X asks Dr. Y to undergo a consultation on a patient occupying a nursing facility.

Based on CPT® guidelines: “The preliminary inpatient consultation codes (99251-99255), should be employed just once by the reporting provider for a singular hospital or nursing institution to patient for a specific admission. It is necessary for these codes to be documented for consultations given to hospital inpatients, occupiers of nursing institution, or patients occupying a partial hospital environment.”

A consultation is a kind of service offered by a provider whose idea or guidance on the aspect of examination and /or handling of a certain problem is demanded for by a different provider.

The requesting provider undergoes the consultation, records his or her view in the client's medical record, and pass on findings/recommendations with the aid of a written report to the demanding provider or other relevant source.

Consultations demands the need to record three of three basic constituent. The provider undergo a comprehensive history, explicit exam and modest MDM.

The correct code would be 99253