tmorgan808
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Hi,
I have a situation where the provider is billing 99242-25, 95912, 95886. He took a history and under it and says he is there for an EMG. Plus additional info about MRI & meds, pain level
EXAM
GA - Alert & oriented, in no acute distress. Mood, affect, and judgment intact.
Vitals
Lungs - breathing unlabored
Heart -regular rate & rhythm
Gait - He has marked antalgic gait with footdrop of the right lower extremity
Neuro - He has a positive SLR. Decreased deep tendon reflex at the right patella. Decreased sensation over the right L4, L5, and even the right S1 dermatome. Motor strength is noted to be very weak with right dorsiflexion, extensor hallucis longus knee extension compared to the left.
Performed EMG/NCS (all valid documentation)
IMPRESSION
Abnormal EMG study
Study shows electrodiagnostic evidence of right L5 lumbar radiculopathy of a moderate degree.
PLAN
recommend increasing gabapentin. Also prescribed Norco.
Is truly a separately identifiable visit? Or should he only be billing for the EMG/NCS.
I have a situation where the provider is billing 99242-25, 95912, 95886. He took a history and under it and says he is there for an EMG. Plus additional info about MRI & meds, pain level
EXAM
GA - Alert & oriented, in no acute distress. Mood, affect, and judgment intact.
Vitals
Lungs - breathing unlabored
Heart -regular rate & rhythm
Gait - He has marked antalgic gait with footdrop of the right lower extremity
Neuro - He has a positive SLR. Decreased deep tendon reflex at the right patella. Decreased sensation over the right L4, L5, and even the right S1 dermatome. Motor strength is noted to be very weak with right dorsiflexion, extensor hallucis longus knee extension compared to the left.
Performed EMG/NCS (all valid documentation)
IMPRESSION
Abnormal EMG study
Study shows electrodiagnostic evidence of right L5 lumbar radiculopathy of a moderate degree.
PLAN
recommend increasing gabapentin. Also prescribed Norco.
Is truly a separately identifiable visit? Or should he only be billing for the EMG/NCS.