evaluation and management

  1. N

    Wiki Diagnosis discussed

    I have a provider suddenly saying he discussed the diagnosis above but doesn't list what he discussed. Normally I would remove them but then he put the time spent with the patient. Do I leave the Dx with no treatment plan or leave them? 99214 M25.811 S90.221A S90.222A I25.810 D69.3 I73.9...
    • ny2scgirl
    • Thread
    • diagnosis coding evaluation and management
    • Replies: 0
    • Forum: ICD-10
  2. A

    Wiki Can you bill an E/M (LOS) instead of a minor procedure?

    Hello, I am doing research on what types of procedures are NOT significantly separate and are typically performed as part of an exam. So far my research has led me to the following types of services that a LOS is billed instead of the procedure: 1. Pap smears when a patient presents with...
    • arbucklej
    • Thread
    • bundled or billable evaluation & management evaluation and management level of service minor procedure minor surgery procedure code procedure documentation
    • Replies: 0
    • Forum: E/M
  3. L

    Wiki Question on Additional Workup

    An infectious disease physician is called in to consult at a hospital on an inpatient who has cellulitis. The hospitals usually take cultures on the patients as soon as they come in, and so a culture was taken two days before the date of the consult. The infectious disease physician diagnoses...
  4. R

    Wiki Emergency department - 1995 guidelines - determining straightforward/ self- limiting or low

    In the ED would you consider this a straightforward/ self- limiting or low problem in the Emergency department? There was no work up and no treatment administered. Case scenario: Female otherwise healthy presents today for evaluation of unknown substance splashed in RI about 6 hours prior to...
  5. firetorah

    Wiki Nutrition/Diabetes Counseling Group E/M visit

    OK, here's the deal: I have a physician and a Registered Dietitian who wish to hold group nutrition and/or diabetes counseling sessions. Let's assume the session is 30 minutes long and involves 10 patients. This is their scenario: The physician wishes to charge each patient with an E/M...
    • firetorah
    • Thread
    • counseling diabetic counseling dietician e/m coding eval & management evaluation & management evaluation and management group medical visits group therapy medical nutrition therapy
    • Replies: 2
    • Forum: E/M
  6. C

    Wiki Oncology E/M Guidelines

    Hi there, Do oncologists use 1995 or 1997 guidelines for E/M coding? I'm guessing the answer is both, but I would like some more color on this if anyone could share. Thanks!
  7. K

    Wiki Group Practice Provider Seeing Patients in Different Place of Service.

    We are a group practice that has a few Dr.'s, NP's and PA's in an outpatient mental health professional office setting. If one of our PA's or NP's sees patients in a nursing home outside of the office setting for medication management (E/M) what CPT codes would be used and would there be...
  8. M

    Wiki Billing E/M code for new pt STD screening only

    Our provider sometimes sees new patients at our walk-in clinic who only want STD screening and have no symptoms. An ROS and brief exam are always done. Can I bill an E/M code for these cases or just the lab draw?
    • maryek28@outlook.com
    • Thread
    • e/m evaluation and management new patient screening std
    • Replies: 1
    • Forum: E/M
  9. K

    Wiki Evaluation and Management services

    Hello, Im having trouble understanding E/M services. Can someone explain how to code an e/m if the time the physician spent with the patient doesn't match the history and/or medical decision making? Do i code what can be proven with the history noted? or a higher level of E/M due to the...
  10. L

    Wiki Office Visit 2 days in a row same dx-extensive visit

    I need some help we had a new Dr start and she was internal medicine and now a derm so she has a question regarding coding for a patient with an extensive issue that had to come in 2 days in a row. Pt has extensive (over 80%) of the body erythoderma due to psorisis she saw the patient day 1 for...
    • LBernat7
    • Thread
    • e/m evaluation and management office visit
    • Replies: 1
    • Forum: Dermatology
  11. L

    Wiki History Codes used as DX for F/U Office Visits????

    I have recently seen several of the following scineros and I just wanted to get some clarification: Patient comes in and has a full skin exam and Z12.83 is used as well as all applicable history codes (say Z85.828 hx of BCC or Z85.820) on the office visit that day and maybe the patient has...
    • LBernat7
    • Thread
    • coding advice needed evaluation and management history of
    • Replies: 4
    • Forum: Dermatology
  12. P

    Wiki E/m hpi

    Really quick question..... we are having interoffice 'discussions' on this and I am looking for outside opinions. A patient comes in for pruritus. HPI states info regarding that symptom. Detailed exam is done as patient also has hypertensive kidney disease and DM. Those two issues are...
    • phycoder
    • Thread
    • auditing evaluation and management
    • Replies: 2
    • Forum: E/M
  13. M

    Wiki E/M MDM: Data Reviewed

    How much data points for Lab and rad procedures ordered and interpreted by physicians? If a physician interpreted results of a lab and rad procedure which was performed on previous visit and then ordered another lab/rad during current visit, can we give points under "independent visualization"...
    • Michelle.Mendoza
    • Thread
    • data points evaluation and management medical decision making
    • Replies: 0
    • Forum: E/M
  14. D

    Wiki My physician asked to consult in ER

    I'm a chart auditor for a large urology group and there is some dispute on our providers providing a consult in the ER. Patient is Medicare and we are NOT admitting the patient to our service. I was told that we should be using 99201-99205 or 99212-99215 as the patient is "out patient" and we...
    • dawnchsr
    • Thread
    • consults emergency department emergency room evaluation and management pos
    • Replies: 2
    • Forum: E/M
  15. K

    Wiki Hospital Consult Cheat Sheet

    HI! I work for an orthopedic group and my doctors are on call at a few local hospitals. I was wondering if anyone had any good cheat sheets they could send me for E&M codes? I have not been able to find any great ones. Thank You.
    • KBeaulieu
    • Thread
    • cheat sheet evaluation and management
    • Replies: 0
    • Forum: E/M
  16. K

    Wiki Injection and Office Visit Billed together

    I have a claim where CPT 99213 was billed with modifier 24 along with a code for an injection. The medical record was submitted showing that the patient came into the office for a penile injection and the physician spent time teaching the patient how to self inject. I know that in order for an...
    • Kaylamh326
    • Thread
    • evaluation and management injection modifier 24
    • Replies: 2
    • Forum: E/M
  17. D

    Wiki Assessment and Plan

    I have a few providers who consistently leave their assessment and plan out of their documentation. What is a good way to address this with them? I've provided them with several examples where they list the condition but there is nothing documented beside it and the HPI does not mention them...
    • DeniMCharlotte
    • Thread
    • assessment and plan evaluation and management
    • Replies: 1
    • Forum: E/M
  18. T

    Wiki E & M coding help please

    Please help with correct E&M code new patient office visit an expanded problem focused history, comprehensive exam MDM of high complexity what will the E & M code become
    • thrower4899
    • Thread
    • code comprehensive evaluation and management exam examples history mdm
    • Replies: 9
    • Forum: E/M
  19. A

    Wiki Preventative Visit with E/M

    Under which circumstances could a Preventative Visit/Physical (99396) be billed with a encounter visit such as 99213?
  20. M

    Wiki Opinions on HPI please

    Hi I was wondering if anyone could tell me what elements they would pull from the following HPI. Pt has a history of bladder cancer, transitional cell, advanced initially treated with Gemzar, carbo, Taxol, and had surgery done and there was residual small cell component. She had four cycles...
    • MandyFlagg
    • Thread
    • e&m elements evaluation and management hpi hpi elements
    • Replies: 5
    • Forum: E/M
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