Results 1 to 4 of 4

New patient minor procedure with E/M

  1. Default New patient minor procedure with E/M
    Medical Coding Books
    Hello,

    Many times a new patient will come in with their stated problem which leads to a minor procedure. For example, a patient presents with warts which are then destroyed. In such cases I code only the procedure as the E/M done is included in the procedure. The problem is during the exam the doctor identifies another issue which he documents in the Assessment/Plan. Can I code an E/M for this additional issue even though there is no mention of it in the history - just mention of the warts?

    Thank you for your help.

  2. #2
    Default Hpi
    My understanding is that you can pull HPI from anywhere within the chart note as long as it is information stated from the patient.

  3. #3
    Location
    Hendersonville, NC
    Posts
    51
    Default
    You can code an additional E/M with a modifier IF there is sufficient documentation to support it. Keep in mind, once you remove the elements for the warts from the note, there may not be enough left (separately) to support a modifier 25 on the E/M.

    Also, all carriers I know of will summarily reject a 99201/99211 with a -25, so the other presenting problems would have to be significant enough to warrant a higher level E/M.

    Hope that helps.

  4. Default Thank you
    Yes thank you both for your replies.

    It just seems strange and even inaccurate to completely leave out a documented diagnosis, sometimes there is even medication prescribed etc. But I guess if there is not enough documentation to support the E&M then there is nothing we can link the diagnosis to.

    And there are those that say that wherever in the note there may be an HPI element - no matter if the doctor is documenting the location after doing the exam for example - it can be counted towards the HPI. But I agree with you - it should be what the patient is saying not the doctor.

Similar Threads

  1. Minor procedure
    By cperk in forum Pediatrics
    Replies: 1
    Last Post: 11-04-2014, 09:52 AM
  2. Minor patient bill guarantor??
    By mputerbaugh in forum Compliance General Discussion
    Replies: 0
    Last Post: 08-17-2012, 11:55 AM
  3. minor patient, not present
    By tammster in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 09-29-2009, 04:06 PM
  4. Major Procedure vs Minor Procedure
    By jodie_cave in forum Medicare Regulations
    Replies: 1
    Last Post: 08-26-2009, 02:20 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.