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E&M with Surgical Procedure

  1. Default E&M with Surgical Procedure
    Medical Coding Books
    Needing a little clarification. Have three scenarios but pretty much the same situation and needing to confirm proper coding.

    Est Pt comes in for visit after being seen in ER. Pt was told arm was fractured. Progress notes only include indication of fracture with cast in place but review of systems, past medical and social history was obtained. Is an additional E&M service billable or just fracture treatment? According to understanding from NCCI guidelines no E&M in additional to fracture treatment would be billable due to no additional information to support or a separate problem other then the fracture is documented, correct?

    Est Pt comes in for visit due to bump on back of head getting larger. Review of Systems and Medical/Social history is obtained. Progress note confirms sebaceous cyst noting pt prepped and draped in sterile fashion for cyst removal. Is additional E&M billable or just excision of lesion?

    Est Pt comes in for visit after being seen in er due to fell on floor and hit arm. Review of Systems and Medical/Social history was obtained. Progress notes state swelling with xray done to confirm fracture and splint applied.
    Separate E&M billable or just treatment of fracture?

    Looking for confirmation based on obtaining guidelines from CMS but there has been discussion regarding accuracy of this so wanting any feedback would be appreciated.

  2. #2
    Columbia, MO
    It does not appear that a significant and separately identifiable exam was documented in any of these cases so I say no bill a preocedure only. The exam you have stated in each case is exactly what was required to perform the procedure.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Great...this is how we were coding them but anytime a question comes up we try to make sure we are still on the right track and not misinterpreting what we are reading. Thanks for replying.

  4. #4
    I am very interested in knowing what you billed as "Fracture Care " in your first and third scenarios. Can you please elaborate?
    Peter Davidyock CPC CPMA
    Coastal Coders Conway South Carolina

  5. Default
    1) 25530
    3) 25600

  6. #6
    I may be incorrect and someone please challenge me if I am but for scenario #1 I believe only an E/M would be billable based on your description.
    Scenario #3 would only be the fracture care with no E/M
    Peter Davidyock CPC CPMA
    Coastal Coders Conway South Carolina

  7. Default
    I can see based on the info I gave where it would lead to just a visit code...I will re-review and see if there was more info noted that I neglected to post. Thanks for the feedback.

  8. #8
    I agree with Peter especially on scenario # 1. Fx care can only be billed once. The patient having a cast on already would be his first clue I would think....
    Teresa Kelley, CPC
    Detroit, MI AAPC Chapter member

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