Wiki E/M during operation

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kristinbailey

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My doc was called into exploratory surgery after the primary surgeon noticed blood in the patients catheter fearing he might have nicked the bladder. My doc tried to bill a consult code and the surgery. I informed his that not enough was documented (no ROS or Exam patient was under anesthesia) to bill for an E/M code. He is SURE that there has to be a E/M code we can use when he is called for a emergent surgery. Does anybody know of a code I could use!
Thank you,
Kristin
 
I think just surgery

I think he'll probably have to be satisfied with just the surgical charge. With no exam the only possible codes (using the 2 of 3 requirement) are subsequent hospital visit: 99231-99233 (depending on documentation, of course).

F Tessa Bartels, CPC, CPC-E/M
 
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