split/shared E&M by 2 physicians


Wolfforth, TX
Best answers
I am needing your input on HOW to code the following senario...

Urologist see's pt for visit. During exam, notices vaginal "suture" left from surgery (14 years ago). Tried to remove suture. Unable to do so. Consulted with Gynecologist. Urologist again, tried to remove suture (without anesthesia). Again, unable to do so. Requested that Gynecologist perform procedure. Gynecologist saw patient, removed suture (without anesthesia). OUCH!

Paratheticals state that removal of foriegn body from vagina without anesthesia should be coded with E&M codes.

What level E&M code does the Gynecologist use to bill out this removal of foriegn body...

The first thing you have to detemine is is this a "New Pt" or "Established Pt" visit. Based on info provided by you, this is not a consult but rather a referral from the Urologist. Then you have to see how many of the required elements the Gyn Dr. covered by reviewing the documentation covering the "visit". I hope this helps.