99213-25 with 46600


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A general surgeon I work for billed a 99213-25 with 46600. I asked for the notes because the patients plan denied the 46600 as inclusive to the 99213. In reviewing the notes it appears to me that only the E/M should have been billed. There is no mention of a scope of any kind in the notes, and the notes states that only the perianal skin was examined. I have attached the note below, please let me know if I am on the right track.

Status Report: Patient had I&D of perianal abscess (Office, 1/28/11, 1/31/11). No anal fistual was identified. After that surgery, patient healed nicely. Patient has now noted "something up inside my anus that prolapses and retracts post wiping." He notes occasional rectal bleeding and denies any further drainage from his prior abscess. He denies any fever.

Exam: Perianal skin only: Wound is closed and no longer draining. There is no surrounding erythema, induration, or tenderness. There is no abscess cavity. The previous right perianal induration and erythema is resolved. There are minimal external hemorrhoids.

Plan: 1. Sitz baths p.r.n.
2. RTO here p.r.n.
3. Patient advised to keep stool soft.


Local Chapter Officer
Tacoma, WA
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Provider didn't document properly

If the provider would have documented that anoscopy was done, then the 46600 could have been billed with the 992xx.

That's how I'm understanding things, anyway.