taneckapoe
New
General question to when do you charge professional E/M when a procedure is done too during an ER visit? The account note example below, some coders said they would not charge E/M level to where some said per components of note they thought 99284 along with 12001
Coder thought 99284 and 12001 due to the fact med was given for possible infection, and documentation supports level 4. Others thought nothing above and beyond besides wound be treated so only 12001 for profee would be coded. (besides the facility charges)
Another question is Would you "carve out" and not count musculoskeletal and skin in exam section due to the injury was this location and was treated?
Any supporting documentation to help decide when a pro fee E/M should be billed when a procedure was also done?
EXAMPLE:
Chief Complaint: Animal Bite (Dog, R index finger)
HPI
male presenting to the ED with a finger laceration after a dog bite. Was training new canine dogs at work this morning when one bit his right pointer finger. The wound was wrapped before presenting to the ED. He reports minimal pain and bleeding. He denies numbness, tingling, any previous injury to the finger. He reports the canine is up to date on his vaccines.
Last tetanus: 2013
In addition to the above, I have personally reviewed any medications, allergies, problem list, medical history, surgical history and social history in the health record as of this visit.
Review of Systems
A complete review of systems was performed and is otherwise negative.
Triage Vitals [08/04/22 0835]
Temp 98.5 °F (36.9 °C)
Temp src Oral
Pulse 82
Resp 16
BP (Abnormal) 164/90
SpO2 97 %
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
Appearance: Normal appearance.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Musculoskeletal:
Comments: Right index finger: 1 cm by 1 cm L shaped superficial laceration across the knuckle. No tendon involvement. Minimal controlled bleeding. ROM intact. Strength 5/5. No edema, warmth, or redness noted. CSMs intact.
Skin:
General: Skin is warm and dry.
Neurological:
Mental Status: He is alert.
MDM
male presents with laceration over right pointer finger knuckle after a dog bite. Patient is pleasant, non-toxic appearing, and in no acute distress. After physical exam, do not believe images are warranted at this time. Laceration will be loosely repaired with absorbable suture and dressed. Patient and canine vaccines are UTD. Patient informed of wound care instructions and plan to send him home with abx. Patient agrees and understands, patient will be discharged in stable condition.
Dog bit to middle knuckle of pointer finger. Vaccinations up to date. Will loosely repair with absorbable suture as the laceration is not puncture like and the location over the knuckle. No indication for imaging today. Will send home on prophylactic antibiotics.
Dog bite, initial encounter
Thanks for any info you can give me on pro fee E/M.
Coder thought 99284 and 12001 due to the fact med was given for possible infection, and documentation supports level 4. Others thought nothing above and beyond besides wound be treated so only 12001 for profee would be coded. (besides the facility charges)
Another question is Would you "carve out" and not count musculoskeletal and skin in exam section due to the injury was this location and was treated?
Any supporting documentation to help decide when a pro fee E/M should be billed when a procedure was also done?
EXAMPLE:
Chief Complaint: Animal Bite (Dog, R index finger)
HPI
male presenting to the ED with a finger laceration after a dog bite. Was training new canine dogs at work this morning when one bit his right pointer finger. The wound was wrapped before presenting to the ED. He reports minimal pain and bleeding. He denies numbness, tingling, any previous injury to the finger. He reports the canine is up to date on his vaccines.
Last tetanus: 2013
In addition to the above, I have personally reviewed any medications, allergies, problem list, medical history, surgical history and social history in the health record as of this visit.
Review of Systems
A complete review of systems was performed and is otherwise negative.
Triage Vitals [08/04/22 0835]
Temp 98.5 °F (36.9 °C)
Temp src Oral
Pulse 82
Resp 16
BP (Abnormal) 164/90
SpO2 97 %
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
Appearance: Normal appearance.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Musculoskeletal:
Comments: Right index finger: 1 cm by 1 cm L shaped superficial laceration across the knuckle. No tendon involvement. Minimal controlled bleeding. ROM intact. Strength 5/5. No edema, warmth, or redness noted. CSMs intact.
Skin:
General: Skin is warm and dry.
Neurological:
Mental Status: He is alert.
MDM
male presents with laceration over right pointer finger knuckle after a dog bite. Patient is pleasant, non-toxic appearing, and in no acute distress. After physical exam, do not believe images are warranted at this time. Laceration will be loosely repaired with absorbable suture and dressed. Patient and canine vaccines are UTD. Patient informed of wound care instructions and plan to send him home with abx. Patient agrees and understands, patient will be discharged in stable condition.
Dog bit to middle knuckle of pointer finger. Vaccinations up to date. Will loosely repair with absorbable suture as the laceration is not puncture like and the location over the knuckle. No indication for imaging today. Will send home on prophylactic antibiotics.
Dog bite, initial encounter
Thanks for any info you can give me on pro fee E/M.