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Level of EM

  1. Red face Level of EM
    Medical Coding Books
    Please help me with this PT.

    Pt is known to have both meniscal damage as weell as arthritis to her right knee. She suffers from Parkinson. She is limited in her ambulatory activities secondary to that and more recently with her knee discomfort. she has had a injection back in Nov. She normally receives an injection perhaps one to three times per year over the last several years.

    Her knee today is consistent with previous examinations.

    After Bedadine prep her knee was injected with 3-4cc Lindocaine adn 2cc Depo-Medrol 40, which she toerated well. She will follow up.

    Can I bill level 3? She is a established PT. Thanks

    Here is another one I would like to know what to bill with and injection.

    Pt is known to have right osteoarthritis. She has had a previous injection in March of last year and noticed relief and a comfortable feeling to that knee up until more recently.

    Her right knee exam today shows no swelling or soft tissur effusion. She has diffuse medial greater than laterl sided tenderness. Medial side pain with deeper flexion. Her quad strength is 4+ to 5. She has normal sensation to light touch. Hip range of motion is comfortable. There is no brusing redness or warmth.

    After sterile prep her knee was injected with 3-4cc Lidoccaine and 2cc Depo-Medrol40 whichshe toterated well. She will follow up.

    Thanks so much for helping.

  2. #2
    I have time to do the first one real quick ...

    mod factor -- injections, modified ambulatory activities
    right knee -- location
    1 ROS -- musculo (arthritis)
    PMH -- significant for parkinson's
    expanded problem focused

    est problem, worsening
    moderate risk
    low MDM

    that gives me a 99213-25 + your injection & J code (don't know off the top of my head)

  3. #3
    Milwaukee WI
    Default Did patient come FOR injection?
    If the patient was scheduled for the injection, then no separately identifiable E/M at all.

    F Tessa Bartels, CPC, CEMC

  4. #4
    good add on Tessa !

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