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E/M during operation

  1. Default E/M during operation
    Medical Coding Books
    My doc was called into exploratory surgery after the primary surgeon noticed blood in the patients catheter fearing he might have nicked the bladder. My doc tried to bill a consult code and the surgery. I informed his that not enough was documented (no ROS or Exam patient was under anesthesia) to bill for an E/M code. He is SURE that there has to be a E/M code we can use when he is called for a emergent surgery. Does anybody know of a code I could use!
    Thank you,

  2. #2
    Milwaukee WI
    Default I think just surgery
    I think he'll probably have to be satisfied with just the surgical charge. With no exam the only possible codes (using the 2 of 3 requirement) are subsequent hospital visit: 99231-99233 (depending on documentation, of course).

    F Tessa Bartels, CPC, CPC-E/M

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