mantlaua
New
What is your opinion on billing an EM level (modifier 25) with minor procedure 11740 evacuation of subungual hematoma?
Documentation of encounter attached.
My rationale for an EM with procedure wasn't just because an x-ray was performed. Although other body systems were examined other than skin/foot I personally didn't feel other body systems may be pertinent to support a seperate EM level on that alone. We have performed an evacuation of a hematoma's in the UC/ER and we typically do not see an x-ray ordered for a foot/finger hematoma for minor injury such as stubbing of toe or finger caught in house door/desk drawer but may be ordered in instances of traumatic injury such as crushing injury, dropping of a piece of wood on toe or fingers slammed in a car door. The exam of skin/nail exam would support the evacuation of hematoma procedure but didn't feel that an x-ray of this site would typically be used to determine the evacuation of a hematoma procedure nor would it be integral to the procedure since the procedure was not musculoskelatal related but more of nail/skin and felt the additional Medical Decision making for the ordering of the X-ray test with indication of dropping of wood on toe and for further work up to rule out a fracture or dislocation at the site. Although there was not specific musculoskelatal physical exam documented there was musculoskelatal ROS and medical decision making and the x-ray interpretation & report confirmed no musculoskelatal abnormalities or need for further procedures such as TX of fracture or dislocation.
Thank you for your opinion.
Documentation of encounter attached.
My rationale for an EM with procedure wasn't just because an x-ray was performed. Although other body systems were examined other than skin/foot I personally didn't feel other body systems may be pertinent to support a seperate EM level on that alone. We have performed an evacuation of a hematoma's in the UC/ER and we typically do not see an x-ray ordered for a foot/finger hematoma for minor injury such as stubbing of toe or finger caught in house door/desk drawer but may be ordered in instances of traumatic injury such as crushing injury, dropping of a piece of wood on toe or fingers slammed in a car door. The exam of skin/nail exam would support the evacuation of hematoma procedure but didn't feel that an x-ray of this site would typically be used to determine the evacuation of a hematoma procedure nor would it be integral to the procedure since the procedure was not musculoskelatal related but more of nail/skin and felt the additional Medical Decision making for the ordering of the X-ray test with indication of dropping of wood on toe and for further work up to rule out a fracture or dislocation at the site. Although there was not specific musculoskelatal physical exam documented there was musculoskelatal ROS and medical decision making and the x-ray interpretation & report confirmed no musculoskelatal abnormalities or need for further procedures such as TX of fracture or dislocation.
Thank you for your opinion.
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