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Wiki E/M auditing

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Cassid2

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New patient was seen for Hidradenitis Suppurativa. Two prescriptions, labs ordered, intralesional injection, and I&D performed. Provider coded a 99204 as well as coded for procedures. My question is, can you count anything in this scenario towards an E/M? Would the prescriptions and ordering of the labs be counted towards an E/M, or are they included in the procedure CPT?

Opinions would be appreciated.
 
When performing services over and above the typical procedure, you are allowed to add an E&M with a modifier to indicate it. In this case, I would say the E&M is supported because I&Ds don't usually require prescription meds or labs (excluding pathology of the contents of the drainage, if performed). So long as a pertinent history and exam are documented, you should be able to support the separate service.
 
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