There is a debate in out office about billing an office visit with a Catheter change. Can someone please clarify?
Dictation example:
*** is a 67Y male who present today for catheter replacement. He is currently under the care at the VA for urinary retention. He manages this with chronic foley catheter care. He typically has this replaced once a month but the home care nurse had difficulty placing the catheter. He has a history of false passage per patient report. He is s/p a "prostate procedure for retention. He has a history of cervical fracture with extremity weakness.
ROS: Other than state above, there are no general, ROS, HEENT, cardiac, pulmonary, GI, endocrin, neurologic, musculosketeal, dermatologic, or psychiatric complaints.
BP: 146/83
Pulse: 70
Weight 1**
General: Healthy appearing, no acute distress
Neurologic: Alert and oriented x3. Mental status within normal limits.
Chest: No SOB. Normal respiratory effort.
AbdomenL Soft, non-tender, non-distended. No hernias noted.
GU: Uncircumsied male, normal phallus. Urethral meatus with 2 CM erosion secondary to chronic foley placement.
16 fr Foley catheter placed using sterile technique. 5 cc of 2% Lidocaine jelly injected per urethra. Foley placed without dicciculty with return of clear urine. 10 cc of sterile water used to inflate foley ballon.
Impression
encounter for Foley cather replacement.
This is what is they want to bill. 99213 and 51702
Dictation example:
*** is a 67Y male who present today for catheter replacement. He is currently under the care at the VA for urinary retention. He manages this with chronic foley catheter care. He typically has this replaced once a month but the home care nurse had difficulty placing the catheter. He has a history of false passage per patient report. He is s/p a "prostate procedure for retention. He has a history of cervical fracture with extremity weakness.
ROS: Other than state above, there are no general, ROS, HEENT, cardiac, pulmonary, GI, endocrin, neurologic, musculosketeal, dermatologic, or psychiatric complaints.
BP: 146/83
Pulse: 70
Weight 1**
General: Healthy appearing, no acute distress
Neurologic: Alert and oriented x3. Mental status within normal limits.
Chest: No SOB. Normal respiratory effort.
AbdomenL Soft, non-tender, non-distended. No hernias noted.
GU: Uncircumsied male, normal phallus. Urethral meatus with 2 CM erosion secondary to chronic foley placement.
16 fr Foley catheter placed using sterile technique. 5 cc of 2% Lidocaine jelly injected per urethra. Foley placed without dicciculty with return of clear urine. 10 cc of sterile water used to inflate foley ballon.
Impression
encounter for Foley cather replacement.
This is what is they want to bill. 99213 and 51702