tci ED Coding & Reimbursement Alert - 2006 Issue 2

You Be the Coder: Do I Need a Complete ROS for 99285?

Question: A patient presented in the ED with sudden onset of pain in the left side of his head, nausea, and weakness. We performed a CT scan and lumbar puncture to rule out a subarachnoid bleed. I have four HPI elements, six ROS, two PFSH, and eight organ systems examined. Because of the conscious sedation for the lumbar puncture, the MDM supports a risk of level five. The insurer's coding department reviewed the chart and it disagreed, saying it doesn't meet the requirements for a level-five service. Who is correct?Indiana SubscriberAnswer: In this case, your payer is correct...

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