e/m code help

  1. J


    Hello, I am trying to figure out the best way to capture middle-of-the-night work being done by the Neurosurgeon. He is being called for chart reviews, etc late at night by the Emergency room doctors and he is giving recommendations. He does see the patient for a face to face consult the next...
  2. P

    Wiki Office Visits via video

    First question, is an office appointment that is conducted via video still considered a face-to-face appointment? Second question, the patient is in the office, but the physician is in another state conducting the appointment via video. I believe this would still be billed with modifier 95, but...
  3. B

    Wiki E/M w/IUD removal/insert

    Hi all, I'm looking to get some input on this denial I'm dealing with: The patient came in for an IUD check back on 10/05/2021 (was having issues and was undecided if she wanted to try and replace it). She requested a replacement visit a little over a year later on 11/03/22 and had her IUD...
  4. S

    Wiki E/m section question

    Someone please help me with this question. A 55-year-old established patient is coming in for a pre-op visit; he is getting a liver transplant due to cirrhosis. The physician performs an expanded problem focused history, detailed examination, and moderate MDM. Patient agrees with his...
  5. M

    Wiki E/M

    For new guidelines under Reviewed and Analyzed Data * Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) Would this mean when my provider reviews an MRI? Can I count this as a point?
  6. K

    Wiki E/M and Procedure same day, New patient

    If a patient is referred to us for Epistaxis R04.0 and we have never seen them before, we do the E&M and it is decided that the patient needs a scope. Can we bill a new patient visit and a scope on the same day 99204 with a 25 modifier 31231 Nasal Endoscopy?
  7. J

    Wiki Question: 2021 Updated E/M Guidelines for Office Visits

    I apologize in advance if this question has already been answered. But I am a bit confused, based on the 2021 guidelines the CPT codes and usage for the office visit still contains the corresponding time/duration the provider can spend with the patient. So... do we use the CPT codes based on the...
  8. N

    Wiki Preventative visit with additional coding

    I have a medical chart where patient came in for "well woman" exam; however medications were ordered for Asthma, Anaphylaxis, and Seasonal allergies. Provider goes over the asthma briefly in the subjective part of the encounter - then goes over all 3 within the "plan" part of the encounter -...
  9. A

    Wiki 2021 E/M outpatient changes 99202-99205 99211-99215 vs. 95 Coding Guidelines - Can Doctor pick either one?

    Hello, I understand the new changes for 2021 but I had a doctor question if they can pick either the 2021 or the 1995 guidelines. I am not sure if they can pick a guideline I would think they have to follow the new changes for 2021 only. I know that the 2021 updates are specific to MDM or...
  10. M

    Wiki Can we bill E/M codes on every routine wound care visit?

    I work for a wound care clinic that happens to also offer Hyperbarics treatment to patient with non healing diabetics wound, cosmetic abdominoplasty, hypospadias etc. Now I would like to know if the provider is able to bill and E/M code on every routine wound care visit. For example, patient...
  11. K

    Wiki HPI element

    Good afternoon I have a question in regards to HPI elements for the following example and would appreciate any advise and insight Established Patient visit Reason for visit - HIV Followup Last seen 1.2.2019 CD4 660/30% ,viral load 21 on current meds Dx HIV 2011 . Risk Factor Heterosexual...
  12. A

    Wiki Urgent Care referred to the ED

    Hello - I need some advice on if this can even be coded. We had a patient present at our Urgent Care that was referred to go to the ED. Is there enough information below to support a 99211? Visit Type: Urgent Care Visit Document Type: Chart Note...
  13. A

    Wiki Time doesn't support level selected

    Hello! I have a question.... 99215 was billed (documentation supports this code), but only 25 minutes (>50% counseling was spent with the patient). I understand that a provider can select a higher level of service when time is documented... but can time spent lower the billed service to a...
  14. E

    Wiki Meet and greet?

    Hi there. Wanted to know the opinions of some of my peers about the following chart note and how to code. What are your thoughts? HPI: Establish Care. No other concern today. Has had flu shot. Pt is here to establish care today. She is transferring care from another of our clinics. She denies...
  15. H

    Wiki Billing for extended face to face time

    Our office had a woman come in to get her blood drawn for prenatal labs and due to a extreme needle phobia our provider spent over 90 minutes with her. During this time no other consulting or medical services took place. Is there a way to bill for the time our provider took with the patient? I...
  16. M

    Wiki Subsequent Hospital Visit and Discharge Management on Same Day

    Need help on this please. Thanks! :) How should the physician bill if they provide subsequent hospital care visit before the patient dies on the same day? I know that physicians may not bill for both a hospital visit and hospital discharge management for the same date of service. Scenario: On...
  17. A

    Wiki Care Plan and E/M

    I code for some Chiropractors that do not adjust until the patient's second visit. At the second visit, the Dr. will discuss their findings from the XRay, and create a Care Plan- Educating the patient on how often they need to be seen and what exercises they can do to speed up the process. They...
  18. K

    Wiki Help - can DDS/DMD bill 99215 and 99244

    Help - does anyone out there know if dentists are allowed to bill any of the medical E&M codes? Especially the higher severity codes? I work for an insurance company and am trying to determine if this is contraindicated. I am seeing cases where a dentist billed 99215 and 99244 and am wondering...
  19. F

    Wiki Can you code E/M for STD testing ?

    Coding OB/GYN and we have patient's come in just for STD testing; stating boyfriend cheated or they were exposed to an STD My question is can you code an E/M visit for just STD testing with no signs or symptoms ? example -99212 with Z11.3 ? Or do they have to have signs or symptoms to code the...
  20. F

    Wiki Billing for lab slip visit

    We (billing department) have been told previously that if a patient presents to the office just for a lab slip, that this wasn't a billable visit as we should be able to write the lab req without seeing the patient. Recently we had an immunization clinic in which our provider saw several...
  21. T

    Wiki Office visits

    Good afternoon all, I am having an issue with getting E/M codes paid when I bill other codes on the same day for the same patient. I am at a loss trying to figure out what modifier to use or do I just stop billing the other codes so the doctor will get paid? I was using modifier 25 on all the...
  22. K

    Wiki Diagnosis billing

    On the exam Doctor write notes skin abnormal (Ex:nevus.hyperpigmentation, heart : Abnormal heart murmur,etc.,) Medical decision making he refers the patient to see specialty doctor(derm/Cardi) or write notes follow-up next visit for any improvement can I code (ICD9 Dx) and bill to the...