Coding E&M codes and procedure codes

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I'm a new coder with a hospice agency.

One of our physicians used manual means in the patient's home to perform a reduction of paraphimosis. According to the documentation, this was the reason for the visit.

Is this procedure included in an E&M code or should this service be coded under another procedure code?

When is it appropriate to code both an E&M code and procedure code?

Thank You,
Kelly
 

lmartien

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I have seen 54450 used for what you describe - Foreskin manipulation including lysis of preputial adhesions and stretching.
Since the procedure was the reason for the visit, and the physician did not address anything else separate and distinct, it would not be appropriate to bill and E&M service. It is inherent in the procedure code.
Only when the provider provides that distinct and separate service apart from the procedure is it appropriate to bill the E&M service.

I hope this is helpful to you.

Linda Martien
 

GWENAT

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When coding for ER services, is there always an E/M code billed?

Thank you,
Gwen
 

GWENAT

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I have been coding for several years strictly anesthesia. E/M coding is something that I am very weak in.

Any help would be appreciated.

March 1st patient returns to his surgeons office for postoperative follow up for a cholecystectomy preformed on Feb 15.

Is 99024 appropriate to bill for this service?

Thank you,
Gwen
 

GWENAT

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Help please....
New patient with chief complaint of sore throat.
Exam:
Vitals: temp 101.2, pulse 40, BP 100/70
ENT: Oropharynx is swollen and red. External ears are normal. Tympanic membranes are normal. Cervical lymph nodes are swollen and tender.
ABD: nontender and no masses

Rapid strep negative but did a strep culture given exam and family member currently having strep throat.

Impression:
Sore throat, possible strep throat. Will await culture results. If positive we will call in prescription.

I am looking at E/M codes 99202 and 99203 with ICD 10 Code J02.9. Leaning more toward E/M code 99202.

Is this correct?

Thank you,
Gwen
 
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