e/m code help

  1. K

    Question 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?
  2. J

    Question 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...
  3. N

    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 -...
  4. A

    Question 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...
  5. M

    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...
  6. W

    Question Number of dx/mgmt options

    Good Evening, Quick question regarding the # of dx/mgmt options table, just a few examples: 1st ex: Patient presents with a complaint of sore throat along with left ear pain which was diagnosed as acute pharyngitis and otitis media, assigned 2 points as I see as self limiting. 2nd ex: Patient...
  7. K

    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...
  8. A

    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...
  9. A

    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...
  10. W

    E/M Leveling New patient

    Drug Prescription Evening, Motrin, Tylenol etc... when the mg is above 200 this would be a prescription?
  11. E

    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...
  12. H

    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...
  13. M

    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...
  14. A

    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...
  15. K

    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...
  16. F

    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...
  17. F

    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...
  18. T

    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...
  19. K

    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...