When to bill for E/M

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I am new to coding. I was wondering how do you know if you need to assign a E/M code or a procedure code. This report I am currently coding. E/M is extremely confusing for me and would appreciate any help.

PRE-PROCEDURE DIAGNOSIS: Foreign body in rectum.

POST-PROCEDURE DIAGNOSIS: Foreign body in rectum.

PROCEDURE PERFORMED: Removal of foreign body from rectum, rigid proctosigmoidoscopy.

ANESTHESIA: 2 mg of Versed and 100 meg of fentanyl.

INDICATIONS: This is a 78-year-old male that came to the emergency room with abdominal pain and complaint of a foreign body in the rectum. Abdominal series demonstrated no evidence of free air or perforation but showed a foreign body in the rectum.

DETAILS OF PROCEDURE: After consent was obtained, the patient was placed in the left lateral decubitus position, 2 mg of Versed and 100 meg of fentanyl were administered and on rectal exam, the foreign body could be palpated at the tip but with manipulation, could not be removed, therefore a tenaculum was placed on the edge of the foreign body, breaking the seal and was able to be removed from the rectum. It appeared to be in one piece and followup rigid sigmoidoscope did not demonstrate evidence of perforation or trauma to the rectal mucosa. The patient tolerated the procedure well.
 

btadlock1

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Procedure code - It was written by the surgeon, not the ER doctor, and if the surgeon just happened to be the ER doctor, the E/M portion would have become part of the global surgical package, anyways. When notes are in the format you gave, they are generally going to be for surgical procedures. You can only bill an E/M code with a procedure done by the same doctor on the same day, if a significant and separately identifiable problem was addressed. The notes must make it clear that the doctor went above and beyond the usual pre-service and post-service work associated with the procedure. If you get some free time, read all of the green pages in your CPT book, especially those for E/M and surgery. Those guidelines are extremely important to your success. Hope that helps! :D
 
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Hi,

In ER the rectal FB removed with out anesthesia. Is this procedure is included in the ER CPT. We have CPT code for removal of rectal FB with anesthesia.

Please advise.
 

hari2009

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Foregin body removal from Rectal

Procedure code - It was written by the surgeon, not the ER doctor, and if the surgeon just happened to be the ER doctor, the E/M portion would have become part of the global surgical package, anyways. When notes are in the format you gave, they are generally going to be for surgical procedures. You can only bill an E/M code with a procedure done by the same doctor on the same day, if a significant and separately identifiable problem was addressed. The notes must make it clear that the doctor went above and beyond the usual pre-service and post-service work associated with the procedure. If you get some free time, read all of the green pages in your CPT book, especially those for E/M and surgery. Those guidelines are extremely important to your success. Hope that helps! :D

Hi Everyone,

The foreign body removal from rectal procedure done in Emergency department. Please clarify me whether is this procedure inclusive with Emergency department E&M or not?

Thanks & Regards,
Hariprakash Chinnasamy
 

Tiger

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There is no documentation to support a E&M
The reimbursement for the procedure includes payment for the pre and post evaluation related to the procedure.
 
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