Wiki patient becomes ill right after excision.


Bronx, NY
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Doctor excised a lesion, patient gets ill right after DUE TO the excision. Does this warrant a E&M for extra work? and what would be the best diagnosis code to describe the situation? I don't know should I bill 99212-25 with r11.2, r06.4, r53.1, R10.819 which are pretty much all the symptoms the patient displayed. Or is all this included in post operative care of the excision code?

After completion of surgery, I instructed the patient to make s/r appointment in 10-14 days. Patient
began to feel nauseous and "very sick" while in the waiting room. Patient vomited once, whilst I was in patient's
presence. I took patient to the bathroom as patient continued to complain to weakness in her legs. Patient was
hyperventilating in uneven breathing pattern. Stayed with patient in the bathroom as she lied on the floor for 2
minutes. Proceeded to bring a piece of hard candy for patient as she began to calm down and start breathing
more normally. Allowed patient to rest in a dimly lit and quiet room in the back office until she felt better. 10
minutes later, patient complained of stomach cramping and weakness in her legs. Brought patient to bathroom
again. Patient came out afterwards appearing more calm and collected. Patient says she tends to have this sort
of bodily reaction every time after she has a minor surgery. Patient denies that she has any family members or
friends around the neighborhood that can accompany her home. Patient insists that she feels better and is well
enough to go home and rest. Patient appears well and gait is steady as she leaves office.
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Based on what is listed above I would consider this part of the procedure. Other than allowing the patient to rest and providing them with candy it does not appear that additional services were rendered. Since the episode was related to the procedure, no additional examination or assessment was provided, it would be inclusive.