Wiki E&M help

[sashat2@yahoo.com]

Pt presents for followup to bx results/tx. Results are SK's and AKs. Pt is treated w LN2 for AK. I billed 17000 only for the AK.
Provider continuously wants to bill E&M for benign diagnoses, when no futher tx needed and pt is instructed to follow up if there are any changes.

Please advise.

 

[KKWood]

E&M billing is not dependent on whether a DX is benign and/or if further TX is needed. If the provider documents a history, appropriate medical exam, and medical decision making, I would bill an OV E&M. If the medical record does not reflect all of these elements then I would not bill an OV E&M. If your provider wants to bill by time, these components still need to be present. So, your best course of action is to look to the medical record and explain to the provider what their documentation supports.

Hope this helps.