E/M Level - A patient came in with a history of breast cancer

BABS37

Expert
Messages
311
Location
Des Moines
Best answers
0
A patient came in with a history of breast cancer and wants her port removed. Physician did a full exam and then did the port removal. Should I code his office visit with it? Just doesn't seem like he really did anything and this looks like a level 2...

any thoughts?
 

purplescarf23

Networker
Messages
98
Best answers
0
Can you post the note? We run into this and depending on the medical necessity of the E/M we would bill it and use an appropriate modifier with the port removal. But we have just removed the port(normally when they are inpatient status).

Kelsey, CPC
 

BABS37

Expert
Messages
311
Location
Des Moines
Best answers
0
Sure! Here's what I have for his H & P.

History of present illness:
She has a history of breast cancer and she is in for port removal this am and not other complaints or concerns. She has been feeling well.

Review of systems:
Heart: no angina or palpitations
Lungs: no cough or dyspnea
GI: no diarrhea or constipation
All other systems negative.

Past Medical History:
Vital signs are stable. Afrebile. In general, no distress. Lungs are clear bilaterally. Normal respiratory effort. Heart regular rate and rhythm, no peripheral edema. Chest wall left subcutaneous port is in place. Abdomen soft, nontender.

Assessment:
Stable for port removal.

Plan:
Port Removal.

:)
 

purplescarf23

Networker
Messages
98
Best answers
0
Oh boy is this one tough. My docs have documented little before on some procedures but this one seems a little too light on the documentation. From a compliance standpoint would he/she feel comfortable in an audit with Medicare? Eeeks. As for the level. I don't see any HPI elements to bill a new pt code. I would defer to the 99499 if at all anything for an E/M. Sorry not much help but this one would be going back to the provider if it was one of mine :)

Kelsey, CPC
 

MnTwins29

True Blue
Local Chapter Officer
Messages
1,188
Location
East Greenbush, NY
Best answers
0
Global package

Without going crazy to look for the code you used for the port-a-cath removal, could this H & P be considered part of a global package and should not be billed as a separate E & M?
 
Top