Wiki E&M and Procedure

[shepherddl]

I would like your opinion on this, please.

Pt. walks into the clinic with a laceration due to a fall. Pt. is seen by the doctor for a laceration repair. Doctor also discusses past medical history, patient's current medication--is something off with meds that led to the fall, how is the patient's eye-sight--did that contribute to the fall, etc. Doc listens to the patient's heart, lungs, looks in eyes, ears, etc.

Do you code just the laceration repair or the appropriate E&M level and the laceration repair?

When is it appropriate to just code only the repair and when is it appropriate to code repair and E&M?

 

[bedforak1]

It would depend on the documentation, but I think coding the E/M may be appropriate.

 

[mhstrauss]

It would depend on the documentation, but I think coding the E/M may be appropriate.

I agree--as long as the documentation is there. Based on what you described above, this visit definitely went beyond just a lac repair.

 

[CodingKing]

I agree--as long as the documentation is there. Based on what you described above, this visit definitely went beyond just a lac repair.

Id say the extra assessment may not be medically necessary based on the circumstances of the fall.