nlbarnes
Expert
Another example that I would like to confirm whether or not the E/M is billable. I left out HPI & ROS, etc.
Plan
Bleeding internal hemorrhoids, hemorrhoidal banding of left and right posterolateral internal hemorrhoid columns was completed, please see procedure note for details. He was encouraged to use supplemental fiber and reminded about the importance of hydration. He will f/u with me in 4-6 weeks for further treatment. This consultation took 45 minutes with 40 spent on counseling.
Chief Complaint
internal bleeding hemorrhoids
History of Present Illness
39 y/o male patient presents for evaluation of bleeding internal hemorrhoids. The patient has a long history of hemorrhoids and in fact has had previous hemorrhoidal surgery. He presents after urgent care visit about one week ago for bleeding that began and lasted for five days. He has had no further bright red blood per rectum since. He denies pain or any protrusions from the anus. He states that he routinely has 3-4 bowel movements a day but denies straining. He does do a lot of wiping for each of the movements. He does not use supplemental fiber.
Procedure
Hemorrhoidal banding
The patient was explained the nature of the procedure and consented. An anoscopic with lubrication was passed into the anorectal canal and withdrawn, left and right posterolateral hemorrhoidal columns were doubly banded with some bleeding occurring and the anoscope was withdrawn. The patient tolerated the procedure well without issue.
Plan
Bleeding internal hemorrhoids, hemorrhoidal banding of left and right posterolateral internal hemorrhoid columns was completed, please see procedure note for details. He was encouraged to use supplemental fiber and reminded about the importance of hydration. He will f/u with me in 4-6 weeks for further treatment. This consultation took 45 minutes with 40 spent on counseling.
Chief Complaint
internal bleeding hemorrhoids
History of Present Illness
39 y/o male patient presents for evaluation of bleeding internal hemorrhoids. The patient has a long history of hemorrhoids and in fact has had previous hemorrhoidal surgery. He presents after urgent care visit about one week ago for bleeding that began and lasted for five days. He has had no further bright red blood per rectum since. He denies pain or any protrusions from the anus. He states that he routinely has 3-4 bowel movements a day but denies straining. He does do a lot of wiping for each of the movements. He does not use supplemental fiber.
Procedure
Hemorrhoidal banding
The patient was explained the nature of the procedure and consented. An anoscopic with lubrication was passed into the anorectal canal and withdrawn, left and right posterolateral hemorrhoidal columns were doubly banded with some bleeding occurring and the anoscope was withdrawn. The patient tolerated the procedure well without issue.