evaluation and management

  1. C

    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!
  2. K

    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...
  3. M

    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?
  4. K

    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...
  5. L

    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...
  6. L

    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...
  7. P

    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...
  8. M

    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"...
  9. D

    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...
  10. K

    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.
  11. K

    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...
  12. D

    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...
  13. T

    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
  14. A

    Preventative Visit with E/M

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

    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...