mhartley
New
I am new at coding general surgery and need some help.
I have a provider who saw a patient (in the office) after 6pm on a Friday. The patient presented to the office with the prior PEG tube completely out. The provider placed a new PEG tube but the patient then complained of generalized abdominal discomfort and it was not clear whether or not the tube had peaked into the peritoneal cavity. Because of this, the provider walked down to the radiology dept after hours to complete required paperwork for fluoroscopic evaluation. The fluoroscopic evaluation revealed that there was no extravasation of the contrast into the abdominal cavity. The provider then went back into the medical office, discharged the patient and requested follow-up the following Tuesday.
Per the provider "Total time spent with the patient cleaning her wound, replacing the G-tube, transporting to radiology, performing the fluoroscopy and giving instructions was 90 minutes".
Would an E/M be billable under this circumstance? Any suggestions on where I could go for further research on if this is billable?
Thank you,
Missy
I have a provider who saw a patient (in the office) after 6pm on a Friday. The patient presented to the office with the prior PEG tube completely out. The provider placed a new PEG tube but the patient then complained of generalized abdominal discomfort and it was not clear whether or not the tube had peaked into the peritoneal cavity. Because of this, the provider walked down to the radiology dept after hours to complete required paperwork for fluoroscopic evaluation. The fluoroscopic evaluation revealed that there was no extravasation of the contrast into the abdominal cavity. The provider then went back into the medical office, discharged the patient and requested follow-up the following Tuesday.
Per the provider "Total time spent with the patient cleaning her wound, replacing the G-tube, transporting to radiology, performing the fluoroscopy and giving instructions was 90 minutes".
Would an E/M be billable under this circumstance? Any suggestions on where I could go for further research on if this is billable?
Thank you,
Missy