Wiki Office visit and procedure coding

[wynonna]

Hi. Can someone please give me an example of when an office visit and procedure can be coded for same visit with one problem? As an example, patient comes in with hoarseness and a fiberoptic laryngoscopy is decided upon and performed.
Would it be acceptable to bill both 99203 and 31575 for scope?
Assuming there are no other symptoms or diagnoses being addressed and patient is new to our specialty. Time spent not documented.

thank you

 

[natashalage]

Hello, I am not an expert. In my AHIMA coding exercise book, it said if the decision for a minor procedure was done, you can code e/m. In your case, the minor procedure relates to the reason of the visit that is challenging because if there was another reason, that e/m would be more obvious. I also remember that if MD did more work than it usually requires for the minor procedure, that will qualify for E/M. The procedure itself also requires some exam, HPI but it's minimal. I guess we need to judge what is extra. I hope a senior coder will respond to your post with good examples. I know one who friquently answers with comprehensive explanations. This topic was discussed in a past. Try to use the Search button as well.