Wiki Ultrasound During E/m Visit

[adunlap23]

Hello,

What would an ultrasound performed during an E/m visit count as in regard to MDM?

Dictation: I performed a bedside ultrasound of the FCR tendon, which shows fluid accumulation around the FCR tendon, suggestive of FCR tendinosis. Ultrasound of the right median nerve show hypoechoic nerve and loss of normal architecture."

He diagnosed the patient with FCR tendinosis and injected the FCR tendon sheath.

Would the ultrasound count as Independent Interpretation of Tests? FYI: he did NOT bill separately for the ultrasound.

Thoughts?

 

[kdlberg]

It does count as independent interpretation of test, because he actually reviewed the ultrasound itself and not someone's report.

 

[adunlap23]

It does count as independent interpretation of test, because he actually reviewed the ultrasound itself and not someone's report.

Thank you.

 

[adunlap23]

I have another question regarding MDM...
Lets say there's an instance where an E/m can be billed with an injection, but the injection is not available. The patient and the doctor agree to the injection, the order is placed, and the injection is planned for another day. Can I still count this as "minor surgery with no identified risk factors" if the injection is to be performed at another encounter?