I read the article titled Separate E/M with Screening Colonoscopy, Plus Pre-Op Screenings.
I have included a link to it here:
https://www.aapc.com/blog/27288-separate-em-with-screening-colonoscopy-plus-pre-op-screenings/
The patient is referred to the surgeon to have a screening colonoscopy. I have the same question as another posted after the article.
The patient is seen in the providers office on 12/11/2018 and scheduled for a screening colonoscopy.
The colonoscopy was scheduled and done on 01/16/2019.
Is the E/M visit billable when done days/weeks prior to the screening colonoscopy?
Below is a sample note.
Chief Complaint
I need a colonoscopy.
History of Present Illness
He presents for discussion of a screening colonoscopy.
Problem List/Past Medical History
Ongoing
Abdominal tenderness
Encounter for screening for malignant neoplasm of colon
Incisional hernia
Historical
ASCVD (arteriosclerotic cardiovascular disease)
Chronic obstructive pulmonary disease
Prostate cancer
Procedure/Surgical History
Colonoscopy
EKG INTERP ONLY
REPAIR INIT. INC. HERNIA
POSTOP FOLLOW-UP VISIT
Pinning (Left shoulder pinning)
Sling (Bladder sling)
Ventral herniorrhaphy
Stent (Heart stents)
Radical prostatectomy
Medications
HYDROcodone-acetaminophen 7.5 mg-300 mg oral tablet, 1 tab, Oral, Q6H
metoprolol tartrate 25 mg oral tablet, 25 mg= 1 tab, Oral, BID
nitroglycerin 0.4 mg sublingual spray, 1 sprays, Sublingual, Q5MIN, PRN
Plavix 75 mg oral tablet
pravastatin 40 mg oral tablet, 40 mg= 1 tab, Oral, Daily
ProAir HFA 90 mcg/inh inhalation aerosol, 2 puffs, Inhalation, Q4H, PRN
ramipril 5 mg oral capsule, 5 mg= 1 cap, Oral, BID
Allergies
Terramycin (unknown)
aspirin (unknown)
neomycin (unknown)
Social History
Alcohol
Current user, Beer, Daily, 12/06/2018
Tobacco
Tobacco use: Current some day smoker. Type: Cigarettes., 12/06/2018
Family History
Breast cancer: Mother.
Review of Systems
Constitutional: [No fatigue, no fever, no weight change.]
ENMT: [No ear drainage, no hearing loss, no nasal drainage.]
Eyes: [No eye discharge, no vision changes]
Respiratory: [No cough, no dyspnea, no wheezing.]
Cardiac: [No chest pain, no claudication, no irregular heartbeat, no palpitations]
Pulmonary: [No cough, no dyspnea, no wheezing.]
Gastrointestinal: [no abdominal pain, no constipation, no diarrhea, no vomiting.]
Genitourinary: [No dysuria, no hematuria, no vomiting.]
Musculoskeletal: [No muscle weakness, no bone/joint symptoms, no weakness.]
Endocrine: [No heat intolerance, no cold intolerance, no polydipsia, no polyphagia.]
Neurologic: [No gait disturbance.]
Integumentary: [No pruritus, no rashes.]
Psychiatric: [No psychiatric symptoms.]
Hematologic/Lymphatic: [No easy bleeding, no easy bruising.]
Allergy/Immunology: [No environmental allergies, no food allergies.]
Immunizations
Vaccine/Date/Status
pneumococcal 13-valent conjugate vaccine 10/02/2017 Recorded
influenza virus vaccine, live 10/02/2017 Recorded
Physical Exam
Constitutional: [Well developed, hydrated, cooperative, conversant.]
Eyes: [Extraocular movement intact, pupils equal, round, reactive to light and accommodation.]
Neck: [Supple, trachea midline, no thyromegaly, no masses, full ROM.]
Respiratory: [Clear to auscultation bilaterally, unlabored breathing.]
Cardiovascular: [Regular rate and rhythm, no murmurs, rubs, gallops, no JVD.]
Gastrointestinal: [Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly.]
Lymphatic: [No lymphadenopathy noted, no lymph node tenderness.]
Musculoskeletal/Extremities: [Normal gait, no pedal edema, no cyanosis, no clubbing.]
Skin: [Normal temperature, turgor and texture, no rash, intact.]
Neurologic: [No focal neurologic deficits, CNII-XII intact, sensation intact to light touch, moving all extremities.]
Psychiatric: [Awake, alert, oriented x 3, mood and affect appropriate, cooperative.]
Assessment/Plan
1. Screen for colon cancer (Z12.11)
Screening colonoscopy scheduled.
I have included a link to it here:
https://www.aapc.com/blog/27288-separate-em-with-screening-colonoscopy-plus-pre-op-screenings/
The patient is referred to the surgeon to have a screening colonoscopy. I have the same question as another posted after the article.
The patient is seen in the providers office on 12/11/2018 and scheduled for a screening colonoscopy.
The colonoscopy was scheduled and done on 01/16/2019.
Is the E/M visit billable when done days/weeks prior to the screening colonoscopy?
Below is a sample note.
Chief Complaint
I need a colonoscopy.
History of Present Illness
He presents for discussion of a screening colonoscopy.
Problem List/Past Medical History
Ongoing
Abdominal tenderness
Encounter for screening for malignant neoplasm of colon
Incisional hernia
Historical
ASCVD (arteriosclerotic cardiovascular disease)
Chronic obstructive pulmonary disease
Prostate cancer
Procedure/Surgical History
Colonoscopy
EKG INTERP ONLY
REPAIR INIT. INC. HERNIA
POSTOP FOLLOW-UP VISIT
Pinning (Left shoulder pinning)
Sling (Bladder sling)
Ventral herniorrhaphy
Stent (Heart stents)
Radical prostatectomy
Medications
HYDROcodone-acetaminophen 7.5 mg-300 mg oral tablet, 1 tab, Oral, Q6H
metoprolol tartrate 25 mg oral tablet, 25 mg= 1 tab, Oral, BID
nitroglycerin 0.4 mg sublingual spray, 1 sprays, Sublingual, Q5MIN, PRN
Plavix 75 mg oral tablet
pravastatin 40 mg oral tablet, 40 mg= 1 tab, Oral, Daily
ProAir HFA 90 mcg/inh inhalation aerosol, 2 puffs, Inhalation, Q4H, PRN
ramipril 5 mg oral capsule, 5 mg= 1 cap, Oral, BID
Allergies
Terramycin (unknown)
aspirin (unknown)
neomycin (unknown)
Social History
Alcohol
Current user, Beer, Daily, 12/06/2018
Tobacco
Tobacco use: Current some day smoker. Type: Cigarettes., 12/06/2018
Family History
Breast cancer: Mother.
Review of Systems
Constitutional: [No fatigue, no fever, no weight change.]
ENMT: [No ear drainage, no hearing loss, no nasal drainage.]
Eyes: [No eye discharge, no vision changes]
Respiratory: [No cough, no dyspnea, no wheezing.]
Cardiac: [No chest pain, no claudication, no irregular heartbeat, no palpitations]
Pulmonary: [No cough, no dyspnea, no wheezing.]
Gastrointestinal: [no abdominal pain, no constipation, no diarrhea, no vomiting.]
Genitourinary: [No dysuria, no hematuria, no vomiting.]
Musculoskeletal: [No muscle weakness, no bone/joint symptoms, no weakness.]
Endocrine: [No heat intolerance, no cold intolerance, no polydipsia, no polyphagia.]
Neurologic: [No gait disturbance.]
Integumentary: [No pruritus, no rashes.]
Psychiatric: [No psychiatric symptoms.]
Hematologic/Lymphatic: [No easy bleeding, no easy bruising.]
Allergy/Immunology: [No environmental allergies, no food allergies.]
Immunizations
Vaccine/Date/Status
pneumococcal 13-valent conjugate vaccine 10/02/2017 Recorded
influenza virus vaccine, live 10/02/2017 Recorded
Physical Exam
Constitutional: [Well developed, hydrated, cooperative, conversant.]
Eyes: [Extraocular movement intact, pupils equal, round, reactive to light and accommodation.]
Neck: [Supple, trachea midline, no thyromegaly, no masses, full ROM.]
Respiratory: [Clear to auscultation bilaterally, unlabored breathing.]
Cardiovascular: [Regular rate and rhythm, no murmurs, rubs, gallops, no JVD.]
Gastrointestinal: [Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly.]
Lymphatic: [No lymphadenopathy noted, no lymph node tenderness.]
Musculoskeletal/Extremities: [Normal gait, no pedal edema, no cyanosis, no clubbing.]
Skin: [Normal temperature, turgor and texture, no rash, intact.]
Neurologic: [No focal neurologic deficits, CNII-XII intact, sensation intact to light touch, moving all extremities.]
Psychiatric: [Awake, alert, oriented x 3, mood and affect appropriate, cooperative.]
Assessment/Plan
1. Screen for colon cancer (Z12.11)
Screening colonoscopy scheduled.
