A 58 yr old patient with rectal bleeding was seen in the office of a gastroenterologist provide advice about this case. The specialist conducted a comprehensive history and exam, and medical decision making was high. The consultant documented his findings and communicated them via written report to the primary care physcian. The patient has private insurance. what is the correct code?
99244
Based on the description provided, the correct code for this case would be a CPT code for an Initial Hospital Care, Comprehensive Level, which is typically used for new patients admitted to the hospital or seen in an office setting. This code captures a comprehensive history and exam, as well as high complexity medical decision making.
To find the specific code, you would need to refer to the current edition of the American Medical Association's Current Procedural Terminology (CPT) book. In the CPT book, you would typically find different codes for initial hospital care based on the level of complexity (such as low, moderate, or high) and the place of service (such as office, hospital, or emergency department).
To accurately select the right code, you would need to review the detailed documentation provided by the gastroenterologist on the findings, procedures performed, and the medical decision-making involved in this specific case. The CPT book also provides guidelines and definitions for each code, which should be reviewed to ensure the correct code is selected.
As the code selection process can be complex and requires knowledge of the specific documentation, it is recommended to consult coding guidelines, resources, or seek expert advice to ensure accurate coding and billing.