Wiki Does this support reporting an E/M service code?

[MEBarnes82]

A patient was seen in our clinic for cerumen removal. During intake, the patient’s blood pressure was noted to be elevated at 126/78. The patient also has a known history of hypertension.

The cerumen removal procedure was performed. In the plan section of the provider’s documentation, it states:

1. Impacted cerumen of the left ear
2. Essential hypertension – continue lisinopril 20 mg, orally

My question is:

Does the documentation of continuing the patient’s existing blood pressure medication (without any adjustment or additional evaluation) support reporting a separate E/M service in addition to the cerumen removal?

Thank you in advance for your guidance.

 

[betsycpcp]

This is an unofficial opinion, but I wouldn't think that would support an E/M service - for one thing the blood pressure is only a little bit elevated, so I would be surprised if there was really any decision making done. Maybe if the patient was concerned - for example if it was a trend and they asked if any change was needed, and the provider said we'll keep an eye on it and make changes if necessary. If all they did was what is noted above I wouldn't expect to see an E/M code.

 

[MEBarnes82]

This is an unofficial opinion, but I wouldn't think that would support an E/M service - for one thing the blood pressure is only a little bit elevated, so I would be surprised if there was really any decision making done. Maybe if the patient was concerned - for example if it was a trend and they asked if any change was needed, and the provider said we'll keep an eye on it and make changes if necessary. If all they did was what is noted above I wouldn't expect to see an E/M code.

Yes, other than the documentation of the cerumen removal this is all that was noted in the progress notes. Management feels because the provider "addressed" the high blood pressure by recommending the patient continue with their current medication it warrants an office visit, it was communicated to me that this is part of prescription management. However, I disagree and feel this is improper coding.